Can You Believe What Happened to Me at the Pharmacy?

This is going to be a rant blog. I happen to know that a lot of people from Aetna (which is my insurer) read this. But, it really doesn’t matter whether it’s Aetna or another medical insurer – they all have the same issues. Thankfully I am reasonably healthy. As with most people, my most frequent encounter with the healthcare system is at the pharmacy. It’s annoying to me to even go to the pharmacy because prices for drugs – even generics – are insane and I have a high deductible plan.

Last month I went to the dermatologist. She e-prescribed three medications for a minor skin issue. I go to the pharmacy and they tell me they only have one. No phone call in advance from the pharmacist, no email from the doctor saying that the medications had been rejected – much less a reason why. So I call Aetna and one of the medications is not covered by the plan. I call the doctor (who is in-network and should know this) to see if a different medication may be covered. They have no idea and give me three others to try. A call back to Aetna and I learn that it’s a skin cream and available over the counter, so it is excluded under the plan. I also learn that I can buy it without insurance for $35. I find that the third medication was approved, it was just on back order. Hours of wasted time.

Yesterday I called my internist. I am going to be out of town and need to renew my Lipitor (yes, I take the generic) earlier than would be allowed. Knowing this would be a problem, I asked the doctor to get a system override. The pharmacist, of course, tells me the system has rejected it. Again, no call from the pharmacy or from the doctor and no system-generated message. I ask the pharmacist why it was rejected and they had no clue. So I told them it was an early renewal and needed an override. The clerk looked at me as if I asked her to solve a quadratic equation. She told me to call my health plan to figure it out. More wasted hours.

Aetna, CVS, Jeff Bezos – it doesn’t have to be this hard. Healthcare has to get easier.

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  1. avatarTom Riekse says

    Craig, good post – after I switched to a high deductible plan I entered this world of price shopping for drugs with none of the convenience of an amazon like buying experience. One of our family members has a allergy that requires an epi-pen. Each time you have to compare the generic, brand name, and cash price. Then you have to compare pharmacies and pricing and availability and mail order, etc.

    In order to save time, I just switched everything to Costco and have them compare the insurance price to cash price. Maybe paying a little more, but I feel they are trying to save some members money.

  2. avatarBarbara Bartelsmeyer says

    Hi Craig – I agree totally – healthcare should not be so hard. With high deductibles, expensive generics, limited formularies (drug lists), pharmacies publishing “cash prices” as loss leaders for cash paying/non-insurance customers, and discount Rx cards – it makes your head spin.

    I’ve been in the PBM business for a long time, and now take my insurance card and 2 discount cards with me for price checking. Like you, I’ve encountered certain drugs excluded – even some generics are on that list! From your post, you seemingly had a perfect storm – a physician’s office unknowingly prescribing a non-covered drug and not explaining that your meds included an OTC, the pharmacist not communicating, a “refill too soon” edit to be overridden and PBM/carriers expecting the consumer to know how to access their online sites to determine what’s covered and cheaper alternatives. All of this to control the cost of healthcare……….

    Issues – How many people just give up out of frustration and don’t take the medications? What price to medical care is the cost of non-adherence? And, yes, to the post from Tom – there are big box stores out there that consistently offer medications at significantly lower costs than chain pharmacies. Unfortunate for independents, however, who provide the ultimate in personal touch, advocating for their customers in the confusing PBM world.

  3. avatarDr. Amarish Dave says

    As neurologist and medical director who is constantly trying to solve problems for my group proactively this story which broadly is created by decentralized formularies and arcane rules for non pain medication refills is one problem i am in the midst of trying to solve. I feel your pain as it is just as frustrating from a providers point of view. So many wasted hours.

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