My Health

Drugs and your Insurance Company
Dec 21, 2006, 14:59

Recently I had the need to visit an allergist to take care of a re-occurring bout of hives. Every few years I get hives. It's generally not a problem. All I need to do is take some pills for a few months and then they go on their merry way. In all the years (about 3 bouts over 7 years) getting the proper medication has not been a problem. In fact the last time I had hives I filled the prescription with my current medical provider, which is Aetna.

The allergist prescribed three medications for me, none of which could be dispensed through the pharmacy. They were all denied. One of the medications, Zantec, is offered over the counter or OTC. Ok, I think the insurance company can make a case for not covering over the counter medication, even though the cost per pill is ridiculous, and once a pill goes over the counter they absolve all responsibility for the medication, which doesnít seem right. The fact that itís available to the general public without a prescription should have no bearing on their part of the payment. But, lets give this one to the insurance company.

The other two drugs need to be pre-certified by the doctor. On the surface this also seems reasonable. What is not as reasonable is that it can take over three days for them to ďapproveĒ it, if your doctor jumps right on it.

This forces you to play ping-pong with the insurance carrier, the pharmacy, and the physician. But even after the fine game of ping-pong the insurance company can simply say, ďNo, I donít think Iím going to cover this because I donít want to. And furthermore, if you check page 754 of the document I know you didnít read when we sent it to you, you have very little recourse.Ē

Luckily, one of the medications was approved and I was able to get my Zyrtec, but the third medication. Allegra, was denied. The Allegra is the good stuff; this is the one that actually works with my condition, given the samples the doctor provided.

So, now youíre sitting there thinking, ďThis is terrible, he canít get his medicationĒ, and you would be partially correct.

There is however two things you can do (other than hunting down the big bad insurance company and firing buckshot through his offices). The insurance company is not saying you canít have it. They are only saying that they wonít pay for it. Sure, this is a real bummer, given the inflated price per pill ($3) because the running joke is that itís paid for by insurance so it doesnít need to be reasonably priced. But, at least you have options.

You can pay the $3 per pill from the pharmacy or you can search out a deal online.

I had heard grumbling of ordering medication from Canada but was never in the situation where I would need to look into it before. What I discovered was a whole world of medication I could order online, and significantly cheaper than ordering from the pharmacy. Sure, itís not the same as ordering with a $10 co-pay for 30 pills but a whole lot better than laying out $90 for my 30-day supply.

- For 90 pills from the pharmacy it would cost $30 if the insurance company covered it.
- For 90 pills without coverage it would cost $270.
- The same pills from an online pharmacy will cost as little as $72.

Sure, this costs $42 more than if insurance covered it, but the savings over getting it in the good old US of A is $198!

After doing a little online research the chart below shows what I found:

Location# PillsCostShippingCost per pill
Paid by insurance30$10.00None$0.33
planetdrugsdirect.com90$72.00Free Shipping$0.80 120$95.00$12.95$0.90
canadapharmacy.com90$99.00Free Shipping (first year)$1.10
Local Pharmacy30$90.00None$3.00

A little more research finds that many of the ďmaintenanceĒ drugs you may be on is also covered. As someone with thyroid issues I am now on thyroid replacement, commonly known as synthroid can be bought for as little $17 for 100 pills. Even with insurance the cost is 33 cents per pill. Online the cost is only 17 cents!

Now sure, Iím not looking to stockpile all the possible medications, but at least there are options. Even with our original Zantac the option to buy the pills OTC or fill the prescription out of pocket is still available if the per-pill cost is less.

Getting older stinks.