re: Snap Shot Of Our Healthcare System Rx Related.

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Walmart says if I want it filled without insurance approval it's $650.00 for 30 days, with Insurance $30.00.

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My daughter's Epilepsy medication is $1100/month without insurance, $7 with

BCBS here as well

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Walmart says if I want it filled without insurance approval it's $650.00 for 30 days, with Insurance $30.00.

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the problem my man is your DR. and the non generic scrips they're writing for you. i have 3 scrips for blood pressure all generic and i get 90 day refills of all three for less than 20 dollars at krogers.

every major drug that's been developed for "stomach issues" over the last 25 years, there been three big ones, prilosec tagamet and pepcid all three developed for the treatment and prevention of ulcers in the early 80's super expensive when they first came out all 3 are now sold over the counter.

here's what you need to do my man go back to your walmart and buy you a bottle of omeprazole that's prilosec generally the most prescribed of the three. 42 tablets will set you back 9 bucks.

It's been this way for years. There are several issues with this, first being the poor communication that occurs when you have a patient, pharmacy, PBM and a doctor all involved. Four entities that don't have a singular ability to see who has the ball in their court.

Doctors rarely ever bother to check who presides over your prescription insurance and will just write you an rx without seeing if its covered or in what tier it is. Takes him a second to write this. Rx gets to the pharmacy who runs the rx and it will go through if its on your insurance formulary. If it doesn't go through, you get a rejection message (which hardly ever helps about why its not covered) and subsequently try and contact the dr to change to something covered.

This can be the start of the shitshow where you now have to rely on your dr to contact the insurance and not sit on their hands. This can take 1-3 days in a dr's office where the staff isn't making tiktok vids or It can take up to 7-10 days in a poorly run office.

If your dr. checked the box "brand only" on the rx, its worse because brands are not typically covered and if they happen to be, they are a high copay. Dr could have avoided this mess by learning to write for generics or at the least write a backup rx for a generic treatment option .

Ex: Dr's like to write for Prevpac's to treat GERD. Its a brand product with three different drugs combined and has no generic equivalent. Its rarely covered, but he could write out 3 separate rx's for the 3 drugs in a Prevpac that are all usually $5 each. You essentially wait for the dr and PBM to hash it out. If any group involved fails at getting things done, its just a back and forth while you wait.

PBM's also have complicated cascades for treatment. They don't want to pay for things that are essentially the same treatment, but where a cheaper way is available (ie the Prevpac example). They will also like to see you treated first with standard therapy that is tried and true and most likely the cheaper route. Once you have checked off these first line therapies and they have not worked, the PBM will start to pay for more expensive treatments. They want to see the cheapest approach tried first before paying for brands, whether or not its the best option for you.

For sure, the entire insurance system created by PBM's gets worse year after year with more headaches and less coverage. In the end though, the largest issue is people not answering faxes, emails and phones. As the years went by, I had a phones stuck to my head 80% of the day trying to get things moving for patients. Its why I don't do it anymore.

Find an independent pharmacy. Most independents will work with you to get you the meds for a little above cost and not worry about the insurance. Yes they frick them over also. BCBS has been fricking them for years so they usually don't mind. Best advice I can give you.

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Just curious what the name of the medication is.

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Linzess

Supposed to help you poop better

My Dr called, BC/BS refused to fill it so he wrote something else which I forgot the name he said.

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The Torch

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Gotcha. I was just wondering. Several years back, my insurance company booted me off Dexilant. I had been on that for years for reflux. They made me start taking Pantoprazole. It's cheaper, but not as effective.

It's amazing that insurance companies can overrule your Dr on prescriptions.

My employer isn't much better. They sent out a memo a few years ago noting that any prescription discounts we get will have to be applied to the part of the insurance they pay for and we would need to pay the full price.

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Walgreens only sold x amount of ounces so they wouldn’t fill the script.

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Had that problem with Walgreens I detest Walgreens

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If your dr. checked the box "brand only" on the rx, its worse because brands are not typically covered and if they happen to be, they are a high copay. Dr could have avoided this mess by learning to write for generics or at the least write a backup rx for a generic treatment option

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This is 100% the doc or his employer chasing supplemental pay.

Drugs are chemicals. There is no difference

I am in healthcare. PBMs are the only thing keeping some of the conglomerates alive. UHC has a 90% medical cost ratio. Optum is Optum Health (YTD margin is 1%), Optum Insight (consulting/tech arm not growing), and Optum Rx (20% growth and very profitable).

Their only way to steer utilization and then revenue maximization are the PBMs. There they can deny you or mark up the drugs significantly higher than your local pharmacy.