Prescription Problems

Can't fill my prescription!

Insurance companies put up hurdles to discourage people from using expensive drugs and to push lower-cost alternatives. These can usually be cleared up by getting your doctor involved.

♦ Just switched plans? Ask for a "transition fill." Medicare drug plans have to give new members a temporary supply of drugs that aren't on their new formulary. Many other plans do too. It buys you time to work things out with your doctor.

Prior Authorization

This is probably the most common hurdle. Your plan won't pay for certain drugs until your doctor sends in paperwork explaining why you need them. It happens a lot with expensive drugs, and it often happens all over again when you switch plans, even for a drug you've taken for years.

Get your doctor's office started on it right away. These requests can take days.

• Watch out for quantity limits too. Some plans only cover a certain number of pills a month, no matter what your prescription says.

Step Therapy

Step therapy is another very common hurdle. It means trying other, less expensive drugs first before "stepping up" to drugs that cost more. Some plans go so far as to require you or your doctor to document that you've already tried the cheaper drugs.

If you've already tried similar drugs, this shouldn't be a problem for your doctor. But if you haven't tried the cheaper alternatives, step therapy can feel pretty restrictive.

Mail order or bust?

The message below sounds pretty ominous, to be sure.

Your plan provides coverage for 2 fill(s) of this medication at a participating retail pharmacy. After this, your plan will require you to pay an additional cost unless you have this medication filled using Express Scripts Pharmacy.

You have filled this medication 1 time(s) at a participating retail pharmacy.

Your plan will require you to pay an additional cost after you fill this medication 2 more time(s) at a participating retail pharmacy.

If you get this message by mail or email, you're lucky.

Most of the time, you go to refill your prescription and find out on the fourth refill that the pharmacy can't fill it. That can be really troubling if you take a critical medication and can't miss a day or two while you get it straightened out.

You might think you got this message because your plan wants you to try a cheaper alternative first (step therapy). But when you're already taking a low-cost generic, the warning seems really strange, until you look a little deeper.

This kind of warning is very common now, especially with HMO-type health plans.

Insurance companies and employers hire a pharmacy benefit manager (PBM) to run their drug benefits. The PBM negotiates rebates with drug makers, decides which drugs are on the formulary, and picks which pharmacies are in the network. They're the middleman in every direction, so of course they make money.

• Express Scripts is the largest PBM in the country, handling almost one out of every three prescriptions. Together with CVS Caremark and Optum Rx, the big three control about 80% of the market. Not a lot of competition there.

Some pharmacies end up preferred, others not so much.

Most plans go a step further and try to get members to order directly from the PBM's own mail-order pharmacy, cutting out the retail pharmacy altogether.

♦ The warning above is misleading. You'd think you can only buy from a retail pharmacy three times and then you have to use Express Scripts. That's not actually so. Many plans have a way to "opt out," as they call it. Most people don't know that.

• If you want to keep buying from your local pharmacy, you can. You just have to call the PBM and tell them you want to keep using your local pharmacy.

The warning always says you might have to pay an additional cost. We found that the cost of the 4th refill was the same as the 3rd. You can easily check your own case by asking the PBM representative what the cost will be.

Mail order might work for you

Maintenance drugs are drugs you've taken for a while and will keep taking. Blood pressure pills are a common example. Almost all plans push people to get their maintenance drugs by mail. Some plans only allow 90-day supplies through mail order.

Almost all plans offer significant savings on generic drugs if you switch to mail order and 90-day supplies.

♦ Express Scripts priced a common generic blood pressure pill for us at $3.20 for 30 days, or $3.90 for 90 days. The total savings over a year won't be huge, but it's still a nice piece of change.

♦ Brand-name drugs, for the most part, don't add up to big savings by mail. In many cases a 90-day supply costs 3 times the price of a 30-day supply. A 90-day supply has to cost a lot less to make this a good option.

• Express Scripts priced a brand-name cholesterol medicine for us at $40 for 30 days, or $120 for 90 days. In this case we don't see the benefit, other than convenience, of going mail order.

♦ Brand-name drugs are especially risky to get by mail. They're expensive to start with. You shouldn't stock up on a big supply unless you're very sure you'll stay on that brand long term.

Keep in mind, a lot depends on how your insurer set up its contract with the PBM. You may find your plan has a good deal. The proof is in the pudding.

• Read all pharmacy communications carefully and know your benefits well.