Aside from failing entirely to care for ourselves medically or the extreme option of death, how can we try and trim our medical expenses? After years in and around the insurance industry, I have a number of suggestions. All will require a bit of investigation on your part. This effort may range from actually reaching a live customer service representative from your insurance company to reading some of the fine print in the coverage manual they send you annually. Your efforts, however, will save you money.
Suggestion: Know Where to Find & How to Use Your Insurance Company’s Formulary
Your insurance company’s “formulary” is their fancy way of detailing what specific medications they will and will not pay for. It changes at least yearly and usually not to a member’s advantage, aside from adding new generic offerings.
The official formulary is sent to you at least annually by mail and I promptly lose mine or throw it away. Luckily, most insurance companies also list the formularies for their specific coverage types on their websites.
Instead of considering the formulary a list of what your insurance company will pay for, you’ll adopt the necessary survival skills faster if you consider this document a list of what will not be covered. Any experimental drug, many older psychiatric medications without lots of lobby money behind them, some very expensive chemotherapies, medications that are expected to be over-the-counter soon and others will not be covered just because. Yes, you supposedly have a formal means to contest, or challenge, whether your insurance company will pay for a particular medication, but the requirements to do so are so demanding that you will lose in the long run. You will never be able to win a game in which your opponent is allowed to make up new rules as the game progresses.
Thus, you need to be prepared to delve into this often-contradictory and whimsical document to save you money and heartache. Let me just mention one example of how exploring this creature more fully can save some money – that is, until the loophole is discovered and the insurance company changes the formulary again.
After a family member’s death to cancer, my doctor and I decided that I might benefit from returning to an antidepressant for perhaps a year. He prescribed medication “X.” Plain old X. Luckily, X, at $110 per month, had been available long enough for there to be a generic version, so I could better afford to pay the $7 co-pay for generics to buy x.
A month or two went by and my doctor decided that I might benefit from the extended release version of X. So off to the pharmacy I went with a prescription for X-XR only to be dumb-founded when presented for a bill approaching $400. It seems there is no generic, no x-XR, for X-XR, and my insurance company wouldn’t pay a penny toward X-XR because. Just because. I continued to take my x and my doctor tried to convince the insurance company to pay for the XR version, all to no avail.
I wasn’t exactly getting better on x, and finally turned to the online formulary to find out why they wouldn’t pay for X-XR. I never did ascertain that, but I found another extended release version of X called X-XL. There was also a generic version, x-XL that could be had for the same amount, $7, that I was paying for x. According to my doctor, only difference chemically between X-XR and X-XL is miniscule. The difference in my quality of life is stunning and the financial difference per month is $393. But unless I had uncovered that other medicine, I’d have either given in to paying for it or continued to have my condition deteriorate.
So, be prepared and then do battle. Enlist all the help you can from your physician and your pharmacist, but ultimately you’re the one that’s going to be standing in front of the cash register with the prescription in hand. If a medication is too expensive and your insurance company won’t pay for it, find out exactly what reason they give. Look up that medication in all its various types in the formulary and double-check with your doctor whether a covered type, if available, could substitute.
Good Luck & Good Health to you!