Can’t find my way out of the insurance maze

I give up. There is no way I’m ever going to understand the ins and outs of our health insurance system as it pertains to prescription drugs.

Tier 1, Tier 2, Tier 3, nonformulary, generic – the terms are developed to confuse.

Under my plan, which I’m thankful to have by the way, I have a $1,500 deductible to pay before most services and co-pays kick in.

With prescriptions, at least as I understand it, the deductible only applies when I purchase nongeneric drugs. With generic drugs and preferred formulary drugs I can get by paying co-pays ranging from $10 to $45. So, I head to the drug store this past weekend and end up paying more than $90 for a generic drug. What? I thought generic drugs were subject to co-pays.

After speaking with three insurance representatives I learn that this particular drug, which I was forced to take because the nongeneric drug was not covered by insurance at all, is now nonformulary and not subject to co-pays. That’s even though the drug is a generic of a generic – you can’t get much more generic than that.

“Call your doctor and get one on our list,” the insurance lady says.

I’ve already done that twice before. The real thorn in my side is that this particular drug for acid reflux, which millions of Americans have, is widely prescribed and is not that not expensive – around $120 for a month’s supply. My insurance company has moved me from aciphex to protonix to pantoprazole.

After checking around on line, I was hit with a surprise. Pantroprazole is the most expensive of the three at $4.13 per pill. In the mail, I could get the other two for prices ranging from less than $1 to $2. Even on-line, pantroprazole is the highest cost of the three. I didn’t pick the drug; I can’t even pronounce it. What is wrong with this picture?

So who picks what drugs we can take? To find out I went to several health insurance companies’ websites. Guess what? It’s a committee of doctors and pharmacists who decide what drugs end up on formularies based on the “most value. Huh? The most value? Shouldn’t drugs be included because of what people need and doctors prescribe?

Unless we want to pay the full bill, it’s the insurance company that dictates what type of medicine and care we receive. It doesn’t matter that your doctor prescribes a certain kind of medicine; what matters is whether or not your insurance company will help with the cost. This may seem like sour grapes because some people have no health coverage at all and struggle to pay medical bills. Even with insurance, I still pay around $4,000 a year, including premiums, co-pays and the deductible, so don’t tell me I can’t complain.

It’s like opening a present every time you step up to the pharmacy counter because you never know exactly what you are going to get ­– or pay.



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