Last week’s article titled “Prescription Coverage Dilemma”  described problems I encountered filling a prescription I’ve used for the past five years. The process used to fill non-preferred scripts is convoluted, and all parties suffer the consequences. I received many comments from last week’s column describing similar problems.
One Blue Cross Blue Shield member found the generic drug he was prescribed ineffective; his doctor wrote a script for the brand name medication, a 90-day supply. The pharmacy wanted to charge him $700 for a one-month supply. He sent the script to their mail-in service instead and received a 90-day supply for only $125!
A NALC (High Option) member tried refilling three different brand name medications. Her doctor wrote several waiver requests and was advised that three alternatives must “FAIL” before they would consider granting a waiver. She ended up purchasing them from Canada.
Another Blue Cross member had a similar situation with a prescription for Eucrisa, a cream used for eczema. No generics were available. After several attempts it was approved for a copay of $350. The doctor gave her a discount card and out-of-pocket expenses decreased to only $10!
This week, I spent hours on the phone talking with customer service reps and reviewing plan brochures to better understand the process. Knowing what to expect doesn’t mitigate the need for change.
According to GEHA, our prescription benefit includes the Advanced Control Specialty Formulary (ACSF). This formulary incorporates step therapy, where a generic/preferred medication is used prior to a non-preferred medication. The formulary is reviewed quarterly, and medications may change formulary status, including preferred to non-preferred. I believe most, if not all, of the Federal Employees Health Benefit Plans follow this guidance.
Basically, providers identify preferred medications for specific conditions. Up until this year, Asmanex was a preferred asthma medication. It changed to non-preferred and according to GEHA, members using this drug were sent a change notice. I don’t recall receiving it.
There are four medications on the preferred list when you search for Asmanex. I was prescribed Pulmicort and it produced serious side effects along with another medication I took previously. My doctor submitted two Asmanex scrips over the next month and both were rejected for lack of supporting data.
My situation should be resolved shortly, GEHA will provide guidance to doctor’s offices to help them through the process and I sent my doctor additional supporting information this week. After more discussions with GEHA, I discovered two primary reasons for disapproval. The first one involved an incorrect ICD diagnosis code. I have Asthma that triggers acute bronchospasms. The first doctor I went to for this condition listed the diagnosis as acute bronchospasms instead using the code for asthma. Secondly, doctors have to list alternate prescriptions that proved ineffective and describe the current medical situation in writing. This process is time consuming, frustrating for all concerned, and puts and undue burden on our doctors. It must be streamlined.
CVS Caremark manages GEHA’s prescription program. To check your medications availability, visit their website  and register by entering a user name and password to start your search. Click on Plan & Benefits, select Check Drug Costs & Coverage from the dropdown menu, and enter the name of your medication and dosage. Your medication will show up with alternatives if it isn’t a preferred drug. It also lists monthly and 90-day supply costs. All plans should offer a similar option on their sites or call their customer service for this information.
The last option is to appeal the denial in writing. You or the provider can submit an appeal. However, the process is lengthy; patients must provide written consent to their physician’s office if the doctor’s office submits the paperwork. Supporting documentation includes medical records, clinical notes, test results and other pertinent information.
Some of those who commented on last week’s article purchased medications from Canada at considerable discount. Currently, it is illegal and the FDA can seize your shipment. If you are inclined to do the same, read the article titled “Amid Pandemic, FDA Seizes Cheaper Drugs From Canada”  that was recently published by Kaiser Health News. Prices at Canadian pharmacies vary widely and delivery times range from 6-8 weeks. Before the pandemic, it took about 2 1/2 weeks.
I checked my prescription’s cost on PharmacyChecker.com and Asmanex was almost 60% lower than the local cost, without plan approval. However, with approval my cost would be about half of the Canadian pharmacy cost when using the manufacture’s coupon. The key is getting FEHB plan approval whenever possible or an acceptable alternative.
Personally, I’m apprehensive when it comes to purchasing medications from foreign countries. The U.S FDA regulates the safety and efficacy of medications sold in U.S. pharmacies. That being said, when saddled with extremely high and unaffordable copayments it may be a viable option. If you pursue this route, be cautious and check your sources carefully.
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Disclaimer:Opinions expressed herein by the author are not an investment or benefit recommendation and are not meant to be relied upon in investment or benefit decisions. The author is not acting in an investment, tax, legal, benefit, or any other advisory capacity. This is not an investment or benefit research report. The author’s opinions expressed herein address only select aspects of various federal benefits and potential investment in securities of the TSP and companies mentioned and cannot be a substitute for comprehensive investment analysis. Any analysis presented herein is illustrative in nature, limited in scope, based on an incomplete set of information, and has limitations to its accuracy. The author recommends that retirees, potential and existing investors conduct thorough investment and benefit research of their own, including detailed review of OPM guidance for benefit issues and for investments the companies’ SEC filings, and consult a qualified investment adviser. The information upon which this material is based was obtained from sources believed to be reliable, but has not been independently verified. Therefore, the author cannot guarantee its accuracy. Any opinions or estimates constitute the author’s best judgment as of the date of publication, and are subject to change without notice. The author explicitly disclaims any liability that may arise from the use of this material.
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