He that pays the piper at the pharmacy…
This story from my days working the Nurse Call Line shows where we’ve gone wrong with buying medication.
“I took my prescription to the pharmacy today because I had to be somewhere else after my visit on Friday. The pharmacy said the insurance wouldn’t pay for it unless the doctor gave them more information. But he said I needed to start it immediately, I really need him to call the insurance company right away.”
The nurse is thinking, but does not say…..
On a Saturday?
For an antibiotic that you could have paid $20 for yesterday, and be well onto the path to recovery from your infection by now?
Come to think of it, a pharmacy in Mexico would probably have it over the counter, without seeing the doctor at all. It probably costs less there, too.
But premiums these days are enormous, and people want to get their money’s worth out of insurance. Many Americans feel insurance should cover everything, since healthcare is now a right. So people get upset when they don’t get what they need, when they need it.
Anyone notice that paying directly is the way to get prompt service? When others pay for something for you, they have a say in how the money is spent, and it takes longer.
I wonder… is it just possible that prior auth, indirect payment, and expanding coverage may have something to do with our pharmacy costs going up?
Have we in America completely forgotten that “He that pays the piper calls the tune”?
“I’m sorry, Ma’am, the insurance company is closed on weekends. I will pass along a message, but you will need to contact the doctor’s office on Monday.”
Insurance and Your Pharmacy: the Back Story
Insurance companies list drugs by preference in an approved formulary. Prescriptions for Tier 1 drugs are processed automatically by your insurance when you present your card at a pharmacy. Doctors are familiar with the most common insurance formularies, and write prescriptions accordingly. Patients may not even be aware of their insurance company’s role in determining their medications– until they need a medication that isn’t on Tier 1.
When a patient asks a pharmacy to fill a prescription for a down-tier or off-formulary drug, it will be denied until the prescribing physician provides additional confirmation, known as prior or pre-authorization. Company policy requires the doctor to convince the insurance representative that the (generally) more expensive choice is necessary and first-line drugs will not work for you. Finding the “magic words” to persuade the insurance representative often requires repeated phone calls and multiple forms, or even proof that first-line drugs failed you recently. “Prior Auth” consumes hours every day from doctors and staff at the typical office, contributing to higher medical practice costs and patient charges.
In the battle of wills between the insurance office and the doctor’s office, the real question is whether the patient comes out the winner. Can you ever be sure the final decision was for your health, and not just the easy road or someone’s bottom line?
He that pays the piper calls the tune. Are you calling it at the pharmacy, or is your insurance company?
To become the one calling the tune at the pharmacy:
Web search or call to obtain your health insurance formularies. Find out if your new and routine medications are first-line on the formulary.
Consult with your doctor whether a formulary recommendation is best, and why.
Most patients view an experienced physician’s statement that “This is the medication I have found to work best for this problem” to be a perfectly valid reason — but you should be aware that your health insurance may not agree. Be prepared to make the decision to pay cash because it’s your body and you trust your physician more than you need to have insurance cover this purchase … or not.
Cash is king
Better yet, consider switching from health insurance to Health Sharing Membership, which leaves prescription questions betweeen you and your doctor.
Comparison shopping applies to medications, too. Check local pharmacy prices – especially the independent ones, which may avoid high middleman costs. Ask friends what they do for affordable meds. Especially during COVID, paying cash to local independent or compounding pharmacies allows many people to make independent prescription choices.
For routine medications, I have been happy with various online Canadian pharmacies. Comparing them to GoodRx coupons and price-list for major US pharmacies has often saved me over 50%, while lately the local independent pharmacy beats them all. A 3-month supply saves time and money.
For incredible savings on generics, check out Perrigo Outlet Store, a Michigan treasure.
Always be the final quality check that you have the right med and it’s doing the right things in your body.
He that pays the piper calls the tune. Start calling it!
Originally published December, 2014. Updated January 27, 2022