Coal for Insurance Companies

Dec 22 2014 Published by under Access, MedicoLegal Concerns

Companies providing drug coverage have a perfectly legal way of making patients pay more for drugs. It's all there in the fine print, and I bet you don't even know it.

Your plan likely specifies co-pays for drugs, generics vs brand names, and 30 days vs 90 days. Seems straight-forward, but the fine print actually specifies "up to" a 30 day or 90 day supply. Now, for pills, this language does not matter. For injectable medications, it does. Many shots come in pens and vials with a specific amount of drug in them. The company has probably based each container on a typical dose of some sort, but many patients may need more or less. If that difference is less than a full container, then the insurance company rounds down. Here's the math assuming each container contains 300 units of medication:

Typical Dose = 30 units per day

30 days = 900 units = 3 containers

So what happens if we raise the dose:

Higher Dose = 35 units per day

30 days = 1050 units = 3.5 containers

The company only allows 3 containers to be dispensed (remember, up to 30 days), or a 25 day supply.

What happens if we lower the dose:

Lower Dose = 25 units per day

30 days = 750 units = 2.5 containers

Once again, the insurer rounds down, in this case to 2 containers, a 24 day supply.

Let's assume the monthly co-pay for this drug is $30. The typical patient pays $1 per day out of pocket, while the higher dose patient pays $1.20 per day ($30 per 25 days), and the lower dose patient pays $1.25 per day! Obviously, this calculation does not take into account the annoyance and cost of trekking back to the pharmacy more often. For patients on a tight budget, a 24-25 day refill cycle may leave them reducing or skipping their medication until funds are available. After all, most of us get paid on a monthly or every two week cycle.

Yes, this practice is legal, but I bet Santa knows it's a scam and is updating his naughty list.

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