Some things are so ridiculous that it’s hard to believe it’s true. This story is one of those.
TRUE STORY
– Doctor: “I’m prescribing Doxycycline capsules to get things addressed quickly. Sending to your local pharmacy now.”
– Patient: “Great. Thank you.”
A few hours later …
– Pharmacist calls patient. “Your insurance is denying this prescription because it’s prescribed in CAPSULE form. The TABLET form is covered. We’ll call your doctor and see if they can resend the prescription.”
– Patient: “Ok. Thanks.” (silently, Patient also thinks: “#@*%$!!!”)
Same medication with same dosage offered in two different forms – tablet and capsule. One is covered by insurance … the other is not. Doesn’t make sense.
But it makes sense if you’re the insurance company – or the Pharmacy Benefit Manager of that insurance plan. The PBM strikes again – working for you to help negotiate costs and provide better access.
“Working for you”. Not really. Why is one form covered and the other is not? Pretty simple. The tablet form is less costly to produce, making it more profitable for the pharmaceutical companies and perhaps for the PBM too.
Never mind that the capsule might start working more quickly. Never mind that is what the doctor prescribed … and they are the EDUCATED and TRAINED medical professional.
It comes down to money. For the gatekeepers and the manufacturers. Money in their pockets … coming out of your pockets. It happens every day with big PBMs. And you’re paying for it if you haven’t explored options for your group health plan. And your employees are paying for it too.
There is a better way, and the advisors at Mitigate Partners can help. Take ONE minute to send an email or call an advisor near you. Setup a quick call to see how we can help.
