The Chicken, The Egg, or The Pharmacy Benefit Tiers

Which came first – the chicken, the egg, or the pharmacy benefit tiers?

I’ve been with four different health insurance companies in my past ten years with diabetes. This doesn’t include the multiple times I was forced to change policies (almost yearly) within the same plan.

pharmacy benefits
From the 94 page packet that came with my new insurance plan

When I was first diagnosed, I was on my dad’s insurance. I remember him leaving my hospital room with a stack of prescriptions to head to the hospital pharmacy. We were shocked at how expensive the test strips were that the endocrinologist had recommended. I remember THAT price tag, but I don’t remember who suggested that we call the insurance company to see if there was a brand that was cheaper.

The insurance company, of course, had a preferred brand. A year later when I started using an insulin pump, I chose not to use the meter that communicated with the pump because the strips were not covered by my insurance at all. Those were my first lessons in the pharmacy benefit tiers.

In the last decade I’ve switched insulin brands and watched those brands switch back and forth across insurance tiers. I’ve switched meter brands more times than I can count and have the plastic bin of discarded meters under my bed to prove it. Port lights and tagging are nice features, but low copayments and accuracy are my only requirements.

I watched a few months ago as all the news came out about Express Scripts and the changes in their coverage. I never received a letter from them – probably because I had already appealed their coverage and my approval was effective through April 2014. When I got my new prescription coverage at the beginning of this month, the first thing I did was dissect the preferred drug list.

I found that the insulin I use was on the fourth tier – the one usually reserved for compounded medications and 10 times the cost of the first tier medications. The test strips I am currently using are on the first tier but there were plenty of brands on the other pharmacy tiers as well.

express scripts quoteI remember the last time that my insulin moved up the tiers on most insurance plans, a discount card was issued to reduce the copay. The test strips that are on the higher tiers of my current insurance all offer copay assistance as well.

Express Scripts claims that they changed their coverage BECAUSE of the discount cards. The discount cards seem to exist to allow/encourage us to use the higher cost prescription products. Am I missing something here or is this just the vicious cycle that comes along with a competitive insurance market? Do I have to wait every year to see who renegotiated their contract and who has the newest discount plan?

A few days ago, one of my coworkers asked me if I’ve always known how to navigate an insurance policy (which explaining some of the details of our new plan). I told her no – not until I had to know.

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