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Insurance and Medication Costs

Let me start by saying that I have good insurance. Patrick is insured through the school district and I have Medicare as a secondary insurance. But, right now, I have had it with insurance and medication costs.

I take a number of medications for my migraine and depression and thyroid dysfunction. Most of my medications are generic and relatively inexpensive, and I'm fortunate to have rather small co-pays through my insurance. I found out last week, though, that one of my medications, extended release topiramate, is costing my pharmacy $200 more per month than they are reimbursed by my insurance (technically, by my insurance's pharmacy benefit manager).

Here's how it works. My insurance contracts with the pharmacy benefit manager to pay for my medication. The pharmacy benefit manager contracts with different drug companies to get discounts my making their drugs "preferred". So, instead of promethazine, I have to take prochlorperazine. It's not usually a big deal if they only cover one medication in a class of medications.

But, PBMs have been doing some pretty nasty things, too. Some of them have put a "gag rule" on pharmacists, not allowing the pharmacists to tell patients when a generic medication would be cheaper than a copay. Others have required that patients use their mail order service. In my case, the PBM is paying the pharmacy less for the medication than the pharmacy is paying for the medication while the pharmacy is only charging me the copay. My pharmacist is currently trying to sort out this situation so I can get my medication without having to sell body parts.

At the same time, though, there is are bills in the Wisconsin Assembly and Legislature designed to help shine some light on the cost of prescription medications and keep PBMs from interfering quite so much between pharmacies and patients. Please read up on these bills and contact your elected representatives (if you are a Wisconsin resident, of course). This is only one small piece of the health care reform that is so desperately needed, but it's a piece that can help lots of people.


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