Determining Prescription Costs with Healthcare Providers

Has anyone else had an insane amount of problems trying to find out if certain healthcare plans cover prescriptions, cover doctors and what else?

I'd love nothing more than to enroll in an Empire Blue Cross Blue Shield plan as they have always been versatile with crossing state lines, including many different doctors in and out of network (based on the plans), but enrollment has closed until late this year, and I don't have this option with the junky NY state of health unless I want to shell out $320/mo. So, I'm considering enrolling in Healthfirst Silver tomorrow, because it's the only cost-effective plan regarding monthly premium vs. a realistic deductible, and would cover prescriptions.

The problem I'm running into specifically is when I try to call the healthcare provider directly after noticing their drug formulary doesn't cover anything other than generic mesalamine and doesn't note the brand, having to be transferred to their CVS pharmacy to confirm what tier drug asacol would be in (to estimate the co-pay cost/coverage) and then wait on hold for 30 minutes while the healthcare provider and CVS talk to one-another, concluding they cannot determine how much the drug would cost, even with a prior-authorization.

This is what ticks me off. I did my research, I spent my precious time on the phone trying to find out if my current doctors would be covered, how much I might be looking to pay for an otherwise $800/mo drug with this insurance, and no one can tell me anything? Such bull.

I will not switch drugs or be apart of an insurance/pharmaceutical model where older drugs phase out of coverage to compete with newer drugs -- this is my life, my health, and everyone should have the right to know how much a prescription drug may cost before purchasing insurance that barely covers jack to begin with.

Has anyone else run into issues like this?

Post Edited (stereofidelic89) : 5/11/2017 10:44:26 AM (GMT-6)

iPoop said...
Huge pain in the butt, right?

Most insurance providers provide a website where you can lookup specific meds. They often have a formulary (preferred meds) and non-formulary list (not preferred meds). You're always best to go based on their formulary/preferred meds as those are the most affordable with least out of pocket costs to you.

I have a policy where non-preffered, brandnamed meds are charged at a 40% of total cost as my copay which is nuts in something like a 30 day supply of lialda which retails for $1,200... which ends up as a $480 copay... Needless to say they got you by the balls and you go with preferred. As not even manufacturer copay assistance cards are that generous.

It's baffling, and that's a terrible price. But here's the thing, I'm trying to be prepared before just buying a plan to know the estimated (not even exact) cost, and no one can tell me! Shame on the pharma industry and healthcare providers for bowing their heads to this. It's such a mess, we probably don't even know who to blame. Asacol should be a relatively inexpensive drug, I know it's been shuffled to the side as newer drugs come on the scene, but disrupting an ill persons preferred regimen for the sake of profits is disgusting.

I'm either going to try and get off it once and for all, or fight this some how. It was already a mess to get a prior authorization to approve it.

And there is no guarantee that the price they quote you today will be the same next month at the pharmacy. Balsalazide (been on it for many years now) doubled in cost over a year ago with no explanation. It's a generic made by more than one maker in the past so there should be some competition in pricing. Not any more and strangely ALL the pharmacies have it for the same price for my insurance. How can this be?

It went down about $10 last month.
There is definitely collusion among drug makers that has nothing to do with name-brand payback for years of research, etc.

To guesstimate your RX cost maybe you can post your zip code and drug needed and ask what insurance people have and the cost of their RX. Could be helpful and AFAIK not illegal yet to crowdsource the best plan.

My experience is that none of the biologics (Remicade, Humira, Entyvio) are on health carriers' formularies for UC, and the carriers will NOT tell you if they will cover these before you get their insurance. My insurance broker confirmed this. It's all on an exception basis only. You choose your insurer and hope they will cover it, based on your doctor's written justification.

But Blue Cross of California has eventually covered​ all my medications at negotiated​ price far below list. I pay 20%, after the deductible.