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fiesty76 (@fiesty76)

Prescription Crazy Maker!

Lung Health | Last Active: May 1, 2021 | Replies (3)

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Arghh! By way of explanation, "the formulary" is another way of saying "your insurance company's list of covered meds" or the "Pharmacy Benefit Manager (PMB)." Both of these can and do change regularly, even if you don't personally change either your company or your plan. The whole PMB issue keeps cropping up in Medicare and insurance legislation because it appears this is what is keeping the prices sky high.

I have learned (the hard way) to "read the fine print" every year when the new insurance plan documents for the Medicare supplement comes out, to see if they are changing anything as far as drug coverage. A couple years ago several of our routine meds were changed from Tier 1 (low copay, no questions) to Tier 3 (HIGH copay, prior approval required) and one was dropped completely. Our med costs went from about $1000/year to almost $4000 - needless to say I went looking for a new provider. At the same time they made major changes to coverage for out-of-area care, and I got hit with $3000 of Urgent care bills.

Now, each year, when out plan brochures are published, I spend several hours reading them carefully, checking coverage & copay changes. Then I go through the exercise of making sure our doctors and medications are still covered by the plan - this sometimes takes a day. I actually go one step farther and call the drug benefit plan people (not the mail order pharmacy) to ask specifically about coverage for my husband's and my meds. Usually I can get a link to the formulary so I can review it.

Some Medicare supplement companies have representatives who will help you through this exercise - just be sure you are talking to a service/medical rep and not a salesperson.


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Replies to "Arghh! By way of explanation, "the formulary" is another way of saying "your insurance company's list..."

@sueinmn, Thank you sincerely for your, as always, very informative and helpful response! When I get beyond my "yard mania", perhaps late fall? Oh, but then there will be leaves and putting the yard to bed, Smiles, I want to count the number of " not approved" letters received from my pharmacy provider, CVS Caremark since Feb, 2021.

My TRS health ins changed on 1/1/21 from Humana to United Health Care but script provider remained the same. At retirement, if one selected the 3rd tier with best coverage and highest prem., one could always move to lower tier but with no guarantee of moving back to higher tier later. When plan changed from orig health provider to Humana, we automatically moved to the combined Humana and Medicare system; this also is true for United...

I can only imagine your shock at the huge increase in med costs from one yr to the next! It is time consuming to read through all yearly changes and I'd become lax about not reading the "fine print" each yr.

Until now, my coverage has been excellent and I'd never had an issue of "out-of-netwk" or "out-of-area") health care experience. Luckily, I learned after going to a new lab and just before my 1st visit with a new specialist that neither were "in netwk". It took several nerve wracking contradictory calls to lab, specialist's office and ins. provider to finally be told both were "in network". The cost otherwise would have been outrageous.

Thanks, too, for the tip to call the drug benefit plan people (not mail order pharm.) to ask about specific meds. Wish I'd known to do this about scripts for this yr. It took from 2/2/21 until 4/ 29/21 to f i n a l l y receive the 2nd rescue inhaler after having yet another letter 2 days bef. giving instr. on how to contest the "denial". .... and instead of it coming from mail order provider, I got a call from local Walgreens that they had the rescue inhaler script ready for pick-up.

Only because of encouragement from grps on Connect have I become an active patient advocate. Thanks to one and all for that!

Otherwise, I would have not had the tenacity to keep asking questions, requesting referrals or explanations. Until the call from Walgreens, I decided that I'd just not "need" a rescue inhaler for 2021. I was worn out from the hassle and have to wonder how many other people just throw up their hands and say "Enough Already, I'm Done"?