Prescription Plan Prices Don’t Always Make Sense

May 19--Joe Grimaldi was sure the pharmacy had messed up when billing his wife for a prescription last month.

She was charged $141 for 60 days of medication. Since his insurance book says it costs $47 for a 30-day supply, he believed she should have paid twice that amount, $94, for 60 days.

"You made a mistake,'" Grimaldi said he told someone at the pharmacy during a phone call.

"No we didn't," the pharmacy employee told him. "That's the way your plan is written."

Grimaldi's appeal to his insurer, Highmark, failed as well. Again, he was told he was billed according to the terms of his plan.

Those terms don't set a price for a 60-day prescription. Anything over 31 days is billed as up to a 90-day supply, Highmark told his wife in a letter.

"It's not right," said Grimaldi, of Upper Saucon Township. "That's written that way for one benefit -- for their benefit."

He didn't like that he couldn't do anything about it. So he contacted the Watchdog, figuring he at least could expose what he considers to be the unfair structure of his prescription plan and encourage people to study theirs so they don't overpay, as he believes he did.

"People don't go into those books. They wouldn't catch it," Grimaldi told me. "Understand your plan."

It might cost less to get two 30-day prescriptions from your doctor instead of one prescription for 60 days, he said.

And don't assume you will save by ordering through the mail, either.

Taking a closer look at his coverage, Grimaldi was surprised to see he would have paid $117.50 for mail order of a 30-day prescription that his wife had filled at the local pharmacy at the same time for $47.

"People figure, 'I save money through the mail, I'm going to send it in,'" he said.

Highmark spokesman Leilyn Perri told me mail order usually is less expensive for people who are on medication for a long time and order in supplies of 90 days.

Grimaldi's plan reflects that. It would cost $117.50 for a 90-day supply of his wife's medications through mail order, compared to the $141 retail price.

Grimaldi doesn't understand why the mail order price is the same for 30 days and 90 days. That doesn't make sense to me, either.

Perri told me he couldn't speak specifically about the Grimaldis' experience. But he said generally customers should talk with their physician about their medication needs and try to structure their prescriptions in the most cost-effective manner based on their insurance terms.

For example, he said, Symbicort is an inhaler with 120 puffs per bottle. If a patient is prescribed four puffs a day, one bottle would be used in 30 days.

If a physician felt it was necessary for their patient to use it long-term, a prescription could be written for three inhalers, a 90-day supply, which could be filled at a pharmacy or through mail order.

In other instances, Perri said, a physician may prescribe only two puffs per day, resulting in a bottle lasting 60 days. That supply isn't the most cost-effective, as it is charged at the up-to-90-day price.

"In these situations, it may be best to ask about coupons or discounts for medications, as well as requesting samples at the prescriber's office," Perri said.

Customers should speak with their doctors about different dosages, strengths or alternate medications, he said. Medications are grouped into tiers, with lower tier medications such as generics costing less. A medication on a different tier may be just as effective and cost less.

The Grimaldis experienced that. Joe Grimaldi told me his wife initially had been prescribed a drug that was on the top tier of their plan, Freedom Blue PPO, and cost $459 to be filled at the pharmacy. She wasn't going to pay that much.

They called Highmark and were told two other medications were similar and were on a lower tier, meaning they would cost less. They checked with the physician, who agreed those drugs would work, as long as she took both.

Perri said customers are encouraged to do as the Grimaldis did and contact Highmark to discuss options.

"We are happy to work our customers through these issues," Perri told me.

Customers who disagree with a decision by their insurer can challenge that decision through the insurer's appeals process. After a decision is made, you have the right to get copies of the documents related to your appeal.

Customers also can seek help from the state Insurance Department. You can file a complaint at www.insurance.pa.gov or 877-881-6388.

The Watchdog is published Thursdays and Sundays. Contact me at [email protected], 610-841-2364 or The Morning Call, 101 N. Sixth St., Allentown, PA, 18101. I'm on Twitter @mcwatchdog and Facebook at Morning Call Watchdog.

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