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My HMO healthplan recently renewed. I'm currently under a labor contract dispute which I thought required that our health plans stay the same as they were when chosen under contract. I also thought that meant my formulary list would remain unchanged as well. Lesson learned.
I just found out a few days ago, after refilling the same Rx for asthma that I've been using for 30 years now, that it's no longer covered. Now, it went from $35 or so on the formulary list my first year up to $50 as a non-formulary my second year. That is when our labor contract ended and plans became "frozen" (union/employer's term, not mine). And from what I've seen up until now, that was true. Premiums, co-pays, basic coverage policy, network providers and... my Rx costs. For 2 additional years (2015 & 2016) my tried-and-true asthma medication (rescue inhaler) was covered as a non-formulary at $50 for a 30-day supply. In May I filled it (still during my 2016 plan year) and the cost (again) was $50, but that refill was recorded as a 16-day supply by Prime Therapeutics (half the usual supply). So first question is why was I charged the same price I've always paid for a 30-day supply even though my prescription plan carrier knows it was only half of that? And why would that change suddenly anyway? It was my 2nd or 3rd refill off an existing Rx, but I just recently realized this error(?) when reviewing my Rx history yesterday.
More importantly, since my plan had gone unchanged for 2 additional years, and I'm in the same situation as before regarding the labor dispute, I did not review my health plan in great detail during my benefit renewal period. Yes, I suppose that, despite everything I've stated above, it was still my responsibility to review everything. However, as I already pointed out, this particular Rx is something I've been using since I was 6 years old. It's a pretty well-known brand and, even though generics and other "similar" brand-name medications exist on the formulary, I have always insisted my doctors specify the brand-name medication on my Rx and I have always been willing to pay the higher and even non-formulary prices over the years. The formula and ingredients may be "similar" or even exactly the same.
However, it is the delivery mechanism I believe to be far superior than the other 2 options available on the formulary. I've tried both many times throughout my life due to the cost, doctor error writing the Rx, or being forced to use the generic form by whichever health plan I had at the time when "do not substitute" wasn't expressed. It is an undeniable fact that the generic brand and the other popular brand-name medication do not provide an equivalent long-lasting dose as effectively as the one I've always used. That's precisely why I prefer it knowing I'll have to pay more for it. Still, the last time I had it refilled (3 days ago) I was told it wasn't covered by my plan at all and I had to pay $90. This Rx has been $78 for the last 3 years, of which my insurance covered $28. So not only do you not cover it even as a non-formulary, it's obvious the reason is the $12 price increase which leaves me paying $90 total ($40 more) for an extremely necessary medication instead of you paying $40 total ($12 more) and leaving me with the other $50.
My BCBS-IL HMO used to be such a great plan. Doctors, nurses and receptionists would honestly say "ooh, that's a great plan" when they'd ask or look at my card. And I love having an HMO plan, especially through a company with such a great reputation and long history of proven service. I also know that it's not going to include all of my doctors in its network forever, nor will it remain this affordable once a new labor contract is agreed to. Yet, I'd still keep it through all of that as long as I knew the medication- the exact brand I've grown to trust and have been using literally my entire life- was covered at least to some extent. The only brand that has worked to treat my most severe asthma attacks when the other "comparable" brands can't push a dose to my airway, much less into my lungs deep enough to alleviate bronchial inflammation. Asthma can be debilitating, demoralizing and even deadly. Which is why I am very disappointed and somewhat distraught at learning that my health insurance carrier for the last 4+ years has now decided to stop covering not just a very common and widely-used brand of medication but, coincidentally, the very same (and only) medication I happen to be prescribed quite regularly and consistently.
Which leads me to my final thoughts/questions. Is my drug formulary list personalized in any way? Or is it pure coincidence that the one medication I need nearly every day of my life is the brand removed from the formulary list after 4 years of helping me cover the cost? Also, I've read that "non-formulary" means "prescription drugs not named on the formulary" but your website doesn't offer a definition for "non-formulary" in your glossary. So what does non-formulary mean according to BCBS-IL and/or Primary Therapeutics (the Rx plan administrator)? If "non-formulary" means what I stated above, then why wasn't my most recent Rx refill covered by the non-formulary cost policy of $50? And lastly, is there a way to petition or argue good reason to have this particular brand of medication added to the formulary? If so, how could I go about doing that?
Thanks,
Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation,
a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
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