Medicine mess: Figuring the calculus of insurance plans

Math has always been a favorite subject of mine. Go figure, I’m Asian! However, in my teeny-tiny hometown in Ohio, we were lucky if we had an abacus or a protractor. Okay, it wasn’t that bad, but when I asked my math teachers to teach us pre-calculus, their response was, “You aren’t Isaac Newton. When are you ever going to use calculus?”

Umm– like when I go to college?

So on the first day of Calculus 101 my freshman year, I thought I was going to have a heart attack when the professor went over the syllabus. I was divided in emotions, multiplied in confusion— in addition to feeling I was rather obtuse.

Should I have known prescription drug plans would be more complex than calculus?

You do the math. Where I now live, there are probably 30 more insurance plans than were available in Charlottesville. This place is HMO’d out the wazoo. I’ve become HMO-phobic! (Get the joke?)

It almost seems there are managed plans within the managed plans. To top things off, many people here don’t have a plain old-fashioned Medicare plan. They have private insurances to manage their Medicare, and if you add Medicaid on top of that, the complexities of prescription drug plans increase exponentially.

If you have a prescription plan, you're charged a certain amount for each medicine. The “deal” your insurance company made with the medicine maker will determine what's covered: everything, a little bit, maybe not so much, very little, and you-owe-us-your-first-born!

In general, generic medications cost the patient under $10 for a month's supply, though some plans will give it to you for “free.”(I put “free” in quotation marks, because really nothing is free. They might just jack up your premium next year.)

I'm always amazed to see how certain plans will not cover a generic medicine that dates back to Abe Lincoln, because they don’t have “a deal” with the medicine maker. Once I was asked to fill out a pre-authorization form that was 100 pages long– and I was going to do it until I saw the medicine cost only $5.55. (WIth pre-authorization, it would drop to $3.)

Do you think a doctor should spend time taking care of a patient with shortness of breath, chest pains, arthritis aches, and severe diarrhea, or be pushed around by insurance companies to jump through hoops like this?

One prominent brand-name medicine became generic about two years ago. To this day, some prescription plans will cover this generic medicine at dirt-cheap prices while other plans will make the patient pay beaucoup bucks.

Why should a cheap medicine cost so much under one plan but not under another? It must depend on which pharmacy plan administrator plays golf with which medicine maker. Unfortunately, that leaves a lot of patients in the rough.

I still have little idea which plans cover what medicines because there are too many plans and too many medications to remember. Plus, it seems the plans change every six months.

I had to get pre-authorization for a cholesterol-lowering medicine at the end of February, and it was rejected twice. Literally one day later– on March 1– I got a letter saying the prescription formula had changed, and now the medicine was available without pre-authorization!

Wouldn’t it be nice if doctors could take care of patients– actually spend time to talk to patients and think about what's best for them– instead of having to justify everything to insurance companies while sick patients wait in line.

(By the way, I got an A+ in calculus!)
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Dr. Hook cracks a joke or two, but he's a renowned physician with a thriving practice and an interesting website. Visit him at dearjohn@drjohnhong.com.