In case you didn’t know, your health insurance company doesn’t really want to pay for your treatment – of any type. One of the easiest ways for them to save money is to reject coverage for your prescription. Most often this is due to a “Non-formulary” medication.
A “Formulary” is a list of drugs which are approved for use in an insurance plan. These are medications they will pay for with no questions asked. There are also “prior authorization required” lists which they will pay for ONLY if your physician completes some certification documents that state that the medication in question is required. The problem comes in that the rules for why they might authorize payment vary widely from plan to plan….Sometimes they require documentation that you have “failed” on other therapies….Sometimes they require a letter from the physician…Sometimes they require the physician’s office to complete a specific form…Sometimes they require a medical review by their case manager…Sometimes they refuse to pay at all. In any case it is quite frustrating for both you and the pharmacist.
Essentially – they hope you will give up and go away or at least pay for it yourself.
Be assured - the pharmacist does not want to tell you that your prescription will not be covered. The pharmacist does not want to have to notify your physician or spend hours on the phone with the insurance company trying to find out exactly what information they need. The pharmacist does not want to make you wait for any of this. The truth is that a single pharmacist can and usually will spend hours each and every day negotiating the maze of insurance requirements to help you get your prescription paid for by your insurance company. The pharmacist is not getting paid for all of this extra effort. Most pharmacists are employees of a large chain and get paid a salary – no profit is included. The pharmacist who works for himself in an independent drugstore only gets paid what the insurance company will pay him – no matter what. Sometimes this means that the $250.00 prescription that you just received netted the pharmacy a whopping $8.00.
You might make it easier on yourself by contacting the physician’s office yourself – to help expedite the process. Occasionally, physician’s offices are slow in “getting back to” the pharmacy. When necessary you can also contact your benefits manager. It is actually their job to help you.
I guess the point is that the pharmacist really just wants to fill your prescription and give it to you. Try to take it easy on the poor guy (or girl). It is a really hard job – dealing with sick people and sick insurance companies all day.
