Our client Doreen relied on her employer-sponsored plan to cover a huge chunk of her medication costs. So when she was laid off a few weeks ago, she needed to find a plan that would cover her much-needed medications. Fast. We signed her up for the one health plan in California that would pay for her medication at a reasonable cost.
When we signed her up for her plan, her medication costs came to around $100. But what she didn’t know was that her prescription was part of a list called a formulary, which is what health plans use to indicate what drugs they will cover. This meant that her health plan was no longer paying for her drugs, and the out-of-pocket cost would’ve been in the thousands. And, since she was no longer employed, paying for it herself was not an option.
What many people don’t realize is that this isn’t a random occurrence. Your medication (no matter how much you need it to live) can be dropped from the health plan’s formulary at any moment without your knowledge. It’s not fair, but it happens often.
So not only was Doreen dealing with that high out-of-pocket cost, but then she found out that she had to wait hours to see her new doctor just to get an authorization to receive her medication. This particular medication was used to treat something severe, so being able to get her medications sooner rather than later was imperative. And even if she could move to another plan, which she technically couldn't, it wouldn't have mattered because the formulary was tied to all of the plans.
Fortunately, we were able to find another way for her to afford her medications through manufacturer's coupons. And we also expedited the process with Blue Shield to get her prior authorizations for future prescription refills.
- Medication is no longer on the drug formulary, skyrocketing the out-of-pocket costs
- Access to much-needed medication stalled because of the health insurance waiting game
- Use manufacturer's coupons, like GoodRX, to bring down the medication costs.
- Sometimes, appealing to the insurance provider can go a long way
Navigating your health insurance can make you want to pull your hair out, especially when something goes wrong, like it did with Doreen. After filling out what seems like the millionth form and making your eighth phone call, you’re left wondering why everything has to be so complicated. But you need to remember that, no matter how unfair the situation, there’s always an alternative solution. Sometimes, you’ve got to get creative to get the results you want. And we’re here to help you along the way.