Prescription drug coverage: the high cost of choice

January 16, 2012 in Health Insurance, Member Stories, News

The recent news about the change in Express Scripts coverage in Massachusetts has led me to think about my own prescription drug coverage. While I still technically have the freedom to choose a pharmacy, the coverage from my provider basically locks me in to its own pharmacy chain (CVS) or else I incur significant out-of-pocket costs. For someone who likes to support local, independent business (including my local pharmacy), this has caused me much angst.

My son has been taking the antiepileptical drug Keppra to manage his epilepsy since 2008. At the beginning, I refilled his prescription monthly: my employer-provided prescription drug insurance (CVS/Caremark) which covered 80% of the cost, and I was responsible for the remaining 20% (approximately $100/month). This was the case no matter which in-network pharmacy I selected (and I preferred to go to a local pharmacy that not only knew me and my family, but also offered more services than the chain stores nearby). In 2011, my coverage changed, particularly with respect to maintenance medications, like the Keppra my son takes. The changes offered savings to those who selected mail order or 90 day supplies of their maintenance medications. The catch? The prescription gets filled by a CVS pharmacy.  If I continued to refill the prescription monthly, at our independent store, I would be responsible for 20% of the drug cost for the first two months and then 50% of the cost for the remainder of the year (approximately $1,750/year). Switching to CVS costs me approximately $650/year, a significant savings, but not without its additional “costs.” The service at CVS is terrible: pharmacists have made labeling/medication instruction errors that I have to tell them to correct, and on three occasions, the pharmacy hasn’t had the full amount of the medication at the time the prescription should be ready. This is unacceptable for a drug I order every 90 days. Should my son go without even one dose of this medication, he can begin having seizures. Unfortunately, the significant cost difference — $1,100/year, nothing to sneeze at! — has me locked in to a subpar option and doesn’t allow me to shop at my preferred pharmacy. I want to be thankful to have an opportunity to save money, but instead, as a consumer, this makes me angry. Am I alone?

4 responses to Prescription drug coverage: the high cost of choice

  1. Hey Ian – just wondering – have you filed a complaint with your employer (assuming they are the ones who agreed to the pharma benefit changes? I wonder if they are hearing from other members.

  2. Hi Martha, I haven’t. For a long time I think I have felt thankful for having good coverage – my son has been able to get any service he’s needed without any question. However, with this change in prescription coverage, and then this year, the introduction of a high-deductible plan, I may want to rethink and let my voice heard now. Lowering costs is an admirable goal, but not if choice or the quality of care suffers.

  3. Ian — This sounds like a specific location issue. Is there another CVS on your way to work or whatever that you could try? (And, does that independent drugstore, have a soda fountain? With almost all the Brigham’s now closed, I need another provider for my addiction :) )

  4. Dennis — You’re right to a certain extent, many of my issues may be with the specific location. However, my kids have required prescription compounds and other medications that I haven’t been able to fill at ANY CVS. That’s why I prefer the independent pharmacy, it was a one-stop shop. I still go there to get other prescriptions (and it is not convenient at all to home or work), and I trust them so much more that I would rather give them all of my business. But my hand is forced by my coverage.

    Unfortunately, no soda fountain — bummer!

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