I just left my local Walgreens where I received my annual flu shot, free by the way and thank you working taxpayers.
While at the counter I overheard several transactions. That will be $2.75. Your co-pay is $5.00.
And then; your one prescription is $3.50, but the other one is not covered by your plan and it’s very expensive. How much? $575 for a thirty-day supply.
It wasn’t covered because it was not on the plans formulary and $575 was the full retail price. That means there is another drug in the same class that likely is on the formulary, covered with the normal co-pay, probably cheaper and for which the insurer gets a rebate.
The patient was in a mild panic. Don’t worry the pharmacist said, we will call the doctor and see if there is an alternative.
What’s wrong with this picture?
Well it’s confusing and inefficient. The patient had no practical reason to investigate the formulary if they even knew what that was. The doctor probably had no idea what the drug cost, whether or not it was on some plan formulary and at the time, likely didn’t know what plan the patient had. The script may have been written from habit or drug company salesmenship; who knows?
The next question is will (should) the doctor allow an alternative drug?
How much more efficient this would be if the patient had been able to give the doctor a card which he could insert in a terminal and instantly see all plan details, the formulary and alternative drugs along with their cost and clinical data. We are just stupid about all this health care stuff and focused on the wrong things…. like the nonsense about competition among insurance companies.
I’m writing this at a shopping mall on my iPhone and yet the patient had to travel to the pharmacy to learn they couldn’t afford their script and the doctor had to learn the facts by way of a call from the pharmacy, but the pharmacist found out using her terminal.
Oh wait, the other solution is just cover all drugs no questions asked which no doubt is the preferred solution in some quarters. Not like that would increase premiums or anything. 🤕