Thursday, July 16, 2009

Healthcare Reform Pt. 3

I'm not a medical professional, I'm just a mom. A mom who has spent a lot of time trying to navigate through inefficient systems trying to get care for my children. I'm going to give you several posts related to many of the headaches I've had to go through in order to get care for my children.

Let me preface this by saying I have health insurance. In fact, I've had the exact same health insurance for the last 12 years from one of the bigger players in the health insurance game. I work for one of the largest employers in the U.S. and have what most think are the "best" benefits around. After reading through my posts, I wonder if you would say we are getting the "best" medical care available to a working family of 4.

Scenario 3 (which could be split into many, many posts, but I'm ready to be done with this topic):

Our prescription drug benefits changed 2 years ago. The change to "save money" requires us order our long-term prescriptions through a mail order company run by the insurance company. You can only fill a prescription 3 times at a local pharmacy before they refuse to cover it.

Here are the fun things about that little change:
  • If you are on the same drug, but the dosage changes, it is still considered part of the long term prescription. So, for example, when my son went from taking 500 mgs. of Depakote ER to 1000 mgs. of Depakote ER and finally to 1500 mgs. of Depakote ER, the insurance wouldn't authorize it at the local pharmacy when we ran low. We ran low because the change in dosage came during the last month of the 3 month supply. There went $200+ I will never see again because I had to pay for it out of pocket.

  • The insurance company "prefers" certain drugs over others without any regard for the individual's needs. My son took Depakote ER for several years (mostly to level out his moods, but it is designed to be a seizure medication). He cycles rapidly - multiple times throughout the day, hour, etc. - going from giddy and happy, to down and finally bottoming out with anger and rage. We tried Risperdal, but it didn't seem to work well. He was zombie-like and extremely depressed. From there we went to Abilify. Abilify has been a gift from God to us because he isn't angry all the time. Guess what? Abilify is not a "preferred" prescription so every time I get it filled through mail order ($800 for a 3 month supply) I have to make sure the doctor notes no substitutions. If he doesn't (he forgot one time) we get Risperdal. Which, oh by the way, doesn't work! GAH!

  • The 3-month supply ALWAYS ends up being more expensive than if I filled the prescriptions locally and paid the 1 month co-pay three times in a row. For example, if I pay $10 to the local pharmacy for a blood pressure medication my husband takes, I would think that the max I would pay with the mail order company would be $30 plus shipping, right? Um, no. That medication costs us around $47 plus shipping for the 3 month supply.

  • Timing is always an issue when filling certain medications. Because we have to pay a larger amount of money at once for a 3 month supply and I have to time the refills around doctor's appointments, I am usually getting refills about 10-14 days out from when the medication runs out. You would think that would give them plenty of time to process the prescription and get it shipped to us, right? Not always. Know what the insurance company told me one time when the medication shipped late because they were out? They offered to have me speak to a counselor to discuss the implications of my child coming off of his medication. Um, thanks, but I know the implications which was why I called you people freaking out that it didn't ship until a week after it was supposed to ship. Talk about insulting.

No comments:

Post a Comment