ON CONSUMERISM
By Arthur Vidro
In May my lung doctor switched me to a different inhaler, called Trelegy.
When I picked up a 30-day supply in May at the Sugar River Pharmacy, my copay was $70. In June, the co-pay again was $70.
In July at the Sugar River counter, while removing $70 from my wallet, I was informed the copay was now $402.66! That’s a $332.66 increase.
My wife kept me from fainting.
I was stupefied. Asked if that was the price with insurance. Yes. Asked if the price without insurance would differ. Yes, it would be even costlier.
Asked if my memory was correct, that the copay the past two months had been $70. Yes, it had.
Did some mental gymnastics. Monthly copay of $400 comes to $4,800 per calendar year. Way beyond our budget.
“Any explanation for why the cost has gone up?”
“Sorry, no,” said Kate from the pharmacy.
Staying soft-spoken, I told kindly Kate I had nothing against her or the pharmacy. “But as for the health insurer,” I said with venom, “this is unjust.”
Kate said the drug maker might have a program to help with the cost.
It’s true that drug makers often have programs to help patients who might fall through the cracks. Still, they list drug prices as high as possible under the assumption that the patient’s insurer will do most of the paying, and that benefit managers will negotiate the list price downward.
Kate found a program for a $100-off coupon, if I qualified and plugged in the information at home. She gave me the website’s address.
Should I go home without the medicine or pay $402 for it? I could try ordering from Canada at a lower price, but that would take time, and when you have breathing problems one thing you run short of fast is time.
I pondered aloud. “Do I need this medicine? Only to breathe. No choice. Between rock and hard place. I’ll take it.”
I pocketed my cash and reached for the credit card.
Back home, I phoned the health insurer (Anthem), stated the prior copays for Trelegy and that day’s copay, and politely asked, “Why the increase?”
The answer, I was told, had to come from another department. The call was switched over. A different person greeted me with the company name of Carelon.
I was now talking to Anthem’s mail-order pharmacy partner.
Then everything clicked into place.
A letter had arrived in late June with this warning:
“Your plan includes two options to get the medication you take on a regular basis. You can switch to home delivery through CarelonRx Pharmacy or continue to pick up your prescription at your in-network pharmacy. If you do not choose, you may have to pay the full cost of your medication.”
That was no idle threat.
Yet in late June I had telephoned Carelon — more than once — to resolve the matter. I had chosen to keep picking up the prescription at Sugar River Pharmacy. A Carelon person typed in the decision and said we were done.
But I guess that selection never entered the right computer system, for the computers in charge decided to raise my copay to $402.
So in July here I was talking again to Carelon.
If I use Carelon, they said, three-month supplies could be mailed to me, so I wouldn’t need monthly refills.
“If a three-month supply is recommended, I’d be happy to pick up a three-month supply at Sugar River.”
Not allowed. The advised three-month supply only applies to pharmacies that have a special deal with Anthem, because that’s more profitable for Anthem.
“I want to continue using Sugar River,” I stated.
The Carelon woman said that’s fine and instructed her computer to let me do so, and to restore the $70 copay.
“At what point does the co-pay change from $402 back to $70?” I asked.
“Right now.”
“Are you certain?”
“Let me check.” After a few seconds, “There, I’ve verified it’s gone through.”
“Earlier today I paid the pharmacy $402 instead of $70. Any way to get the extra $332 returned?”
“That,” said Carelon, “depends on the pharmacy. If they’re nice … ”
“Oh, yes, everyone there is nice. That’s why I use them instead of the pharmacies Anthem pressures me to use. That, and because they always answer the telephone in person.”
I quickly dialed Sugar River and asked for kindly Kate. She went back to the register and, through my credit card, refunded the extra $332.66 I had paid.
A couple days ago the credit card bill arrived, showing the refund had processed perfectly.
Thank you, Sugar River Pharmacy.
But as for Anthem, shame on you.
I wonder how many of its other policyholders lack the time, patience, or know-how to delve deep, and instead surrender in despair or confusion and end up doing without their medicine, or end up paying the outrageous amounts so cavalierly dictated by Anthem.
Guess I’ll never understand health insurance.
