Medical and Financial Tip: Get To Know Your Formulary

I was pretty sick a couple weeks ago, and my family was really nagging me to go to the doctor. I hate going to the doctor because our co-pay is 30 dollars a visit. I have no problem taking the kids, but for myself, I have more of a ‘I can beat this’ attitude.

Anyway, the coughing all night was getting on my nerves, so I gave in and finally went to the doctor. It was a pretty basic visit; my diagnosis ended up being a sinus infection and possibly strep. (No need to swab my throat because he was prescribing me Zithromax for my sinuses, and that would also take care of the strep. He also gave me a prescription for a cough medicine.)

I went to Rite Aid (remember, I swore-off Walgreen’s), and sat to watch CNN in the waiting area after I dropped off my prescription. The pharmacist called me up to the window pretty quick, which always makes me nervous because it usually means there is a problem of some sort. I was right to be nervous, because neither of my prescriptions was covered by my sweet insurance.

I cursed under my breath, but had them filled anyway because I was feeling pretty cruddy, and just wanted to go home. I asked why they weren’t covered, and apparently, these drugs were not on the insurance company’s formulary (aka list of covered medicines). In the case of Zithromax, the pharmacist said many insurance companies don’t cover it because they want you to get something cheap like Amoxicillin instead. That is such a rip-off in when you are allergic to Penicillin like my son is, or when a different drug would do a better job. But, who cares about fair when the intention is to make money hand-over-fist?

On the way to my car, I called my husband and proclaimed that I was never going to the doctor again, and that my little illness was costing the family over a hundred dollars. Now, I know many people do not have health insurance and are in much worse straits. However, I was still mad because we pay over 500 dollars a month for our insurance, and then we have to pay a ton in co-pays and prescriptions on top of that. (We are not self-insured, this is an employer-sponsored plan.)

So, I wonder, how much does this policy of high co-pays and minimal prescription coverage cost the insurer in the long run? How many people can’t pay the hundred dollars and end up waiting until an illness has gotten severe to get treatment? In that case, the insurance may have to pay for hospitalization and a whole lot more. I can tell you the cost makes me think twice about going to the doctor, so I can’t imagine how hard it must be for some other people. It is probably too hard for the insurance company to know how many hospitalizations could have been prevented had the patient gotten care sooner anyway, so probably better to just milk the subscribers as much as possible!

Lesson Learned:

Get to know your formulary so you can request a different medication if you know the medicne the doctor is prescribing is going to cost you a lot of money. I know formularies can be huge, so keep a copy with you in the car and take it in to doctor appointments with you. May seem extreme, but it may save you a lot of hassle and money!

Have you ever felt raked over the coals by your insurance company?