Patients think they have drug coverage in their insurance, but they are WRONG!
Let us pick a disease: Diabetes.
I decide to order metformin. It is cheap and it works. 60 tablets cost $4 at Walmart without insurance. Instead, the patient uses their insurance and goes to CVS, where their drug plan “covers” the medicine. The cost is $25, the usual copay for one month of a generic drug.
Wait! That person just paid an extra $21 to use their drug plan. How is that even appropriate?
If they try to use the GoodRx plan at CVS, the pharmacy will refuse it, saying: “That’s only if you don’t have insurance.” (If you call GoodRx, however, a helpful staff will intervene with the pharmacy and you will get your discount.)
Anyway, the person gets the Metformin.
Flash forward a few months and we find Metformin is simply not working. The patient pushes for one of those fancy drugs like Trulicity. I agree and order it. Insurance denies it and demands I get a prior authorization. The patient asks for the GoodRx price and finds it is $780 per month.
Dang! That’s expensive! Let’s try the prior auth! This means your doctor’s office answers enough questions on covermymeds.com that are so confusing they dwarf anything on the MCAT’s, but ultimately may get the approval.
YOUR MEDICINE IS APPROVED!! WOO HOO!!
The patient goes back to the pharmacy, confident they won’t need to pay $780 per month. Nope! It will be less!
…And it is less! Now, it is $700 per month!
“Um… Really? I still can’t afford that. Can I appeal the copay? Can I get one of those coupons?”
The problem with copay appeals: They are a nightmare for the doctor’s office. The nightmare repeats every six to twelve months.
The problem with coupons: They last six to twelve months for a drug you will need for the rest of your life. They cannot be repeated. Your plan may actually forbid their use.
So, even when you think you have done your due diligence, there is a great chance your drug coverage is a total scam.
We use GoodRx all the time. No pharmacy has refused it because we have insurance.
“If they try to use the GoodRx plan at CVS, the pharmacy will refuse it, saying: “That’s only if you don’t have insurance.” ”
At this point I generally recommend they go to a different pharmacy and don’t tell them they have insurance.
But yeah these $25 copays on cheap meds are one of the biggest scams in medicine.
Follow the money trail!!
Big profits for Big Pharma and Insurance companies!!
That you, the patient, run the risk of bankruptcy….or worse, is completely irrelevant to them!
Bottom line…..don’t get sick in America!!!!