Down the rabbit hole
In the middle of fretting about my upcoming cataract surgery — I am too young for this, I hope the surgeon knows what he’s doing, I hope that when it’s over I’ll see that all this worrying was unnecessary — I did something that seemed straightforward and easy: went to the drug store to fill the surgeon’s prescriptions for eye drops.
“Can’t do it,” the pharmacist said. He explained that two of the drops were not included in the “formulary,” the list of medications covered by the company that manages prescriptions for my Blue Cross HMO. Together, these two medications would cost about $350. The pharmacist offered to check whether the surgeon might want either to prescribe an alternative — a generic or a different brand-name drug included in the formulary — or to submit a request for a formulary exception.
I went home without my eye drops, mildly astonished that the pharmacist and the doctor’s office were going to have to engage in these follow-up actions, which seemed like a waste of their time.
The next day I called my doctor’s office and left a message. No one called back. Two days later, I went back to the pharmacy, prepared to pay for the eye drops out of pocket, using the drug manufacturer’s discount cards given to me by the doctor’s office. But the pharmacist pointed out that though the large print (“You pay as little as $35 and we’ll pay up to $160”) seemed to promise an overall price reduction, according to the small print the cards covered two circumstances neither of which applied to me. If I’d had no insurance, the cards would have reduced my cost drastically. If my insurance had covered these drugs, the cards could have made a relatively minor reduction in my co-pay. But since I was insured by a company that didn’t cover these drugs, the cards weren’t going to help me.
Curious by now about this whole drug company/insurance landscape, I called Blue Cross to see whether its formulary included any comparable eye drops. When I mentioned the first drug, Blue Cross gave me a list of three “covered alternatives.” When I named the second drug, it came up with the same list. Did this mean that my doctor had prescribed two identical, or redundant, medicines? Or was the Blue Cross formulary missing something important? I got off the phone and looked up the two medicines my doctor had prescribed. The first was an anti-inflammatory steroid; the second was a non-steroid anti-inflammatory drop designed to — and this sounded pretty important to me — reduce pain.
The pharmacist called the doctor’s office, and the doctor’s office called me to come pick up samples of the eye drops. So I drove 40 minutes to the office and finally, four days after my first attempt to fill the prescriptions, I had the medicines in hand.
As I drove home, I wondered how many other people all over the country might be scurrying around, or being put on hold, or filling in paperwork, or trying and failing to understand some bit of fine print, having to do with prescriptions. The pharmacists checking with the doctors to make sure the doctors really meant it when they specified these drops or those pills; the doctors filling in paperwork or making phone calls to insurance companies to say that yes, they really did mean these drops or those pills; the patients running around — if they are healthy enough to be mobile — to turn in cards or repeatedly visit drug stores or travel to pick up samples, at a time when they are already worried about whatever condition or procedure they need the medicine for.
The drug companies and insurance companies are fighting about money, a clash of titans that is happening over and over again, above the heads of the people — patients and doctors — affected by it. The drug companies lunge with high-priced patent medicines; the insurers parry by listing generics and “covered alternatives.” The drug companies merge, and the price of generics goes up. The insurance companies revise their formularies and co-pay tiers. The drug companies issue coupons. The coupons may not work. The country doesn’t seem willing to look at single-payer insurance in which the government is able to bargain with the drug companies. The patient doesn’t need eye surgery to see that something is wrong with this picture.
Joan Wickersham is a columnist for The Boston Globe. Her latest book is “The News From Spain: Seven Variations on a Love Story.”