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Medical and Financial Tip: Get To Know Your Formulary

October 12, 2010 · 82 comments

in Health & Fitness, Misc Tips, Personal Finance

I was pretty sick a couple weeks ago, and my family was really nagging me to go to the doctor.  I hate going to the doctor because our co-pay is 30 dollars a visit.  I have no problem taking the kids, but for myself, I have more of a ‘I can beat this’ attitude.

Anyway, the coughing all night was getting on my nerves, so I gave in and finally went to the doctor.  It was a pretty basic visit; my diagnosis ended up being a sinus infection and possibly strep.  (No need to swab my throat because he was prescribing me Zithromax for my sinuses, and that would also take care of the strep.  He also gave me a prescription for a cough medicine.)

I went to Rite Aid (remember, I swore-off  Walgreen’s), and sat to watch CNN in the waiting area after I dropped off my prescription.  The pharmacist called me up to the window pretty quick, which always makes me nervous because it usually means there is a problem of some sort.  I was right to be nervous, because neither of my prescriptions was covered by my sweet insurance.

I cursed under my breath, but had them filled anyway because I was feeling pretty cruddy, and just wanted to go home.  I asked why they weren’t covered, and apparently, these drugs were not on the insurance company’s formulary (aka list of covered medicines).  In the case of Zithromax, the pharmacist said many insurance companies don’t cover it because they want you to get something cheap like Amoxicillin instead. That is such a rip-off in when you are allergic to Penicillin like my son is, or when a different drug would do a better job.  But, who cares about fair when the intention is to make money hand-over-fist?

On the way to my car, I called my husband and proclaimed that I was never going to the doctor again, and that my little illness was costing the family over a hundred dollars.  Now, I know many people do not have health insurance and are in much worse straits.  However, I was still mad because we pay over 500 dollars a month for our insurance, and then we have to pay a ton in co-pays and prescriptions on top of that.   (We are not self-insured, this is an employer-sponsored plan.)

So, I wonder, how much does this policy of high co-pays and minimal prescription coverage cost the insurer in the long run?  How many people can’t pay the hundred dollars and end up waiting until an illness has gotten severe to get treatment?   In that case, the insurance may have to pay for hospitalization and a whole lot more.  I can tell you the cost makes me think twice about going to the doctor, so I can’t imagine how hard it must be for some other people.  It is probably too hard for the insurance company to know how many hospitalizations could have been prevented had the patient gotten care sooner anyway, so probably better to just milk the subscribers as much as possible!

Lesson Learned:

Get to know your formulary so you can request a different medication if you know the medicne the doctor is prescribing is going to cost you a lot of money.  I know formularies can be huge, so keep a copy with you in the car and take it in to doctor appointments with you.  May seem extreme, but it may save you a lot of hassle and money!

Have you ever felt raked over the coals by your insurance company?

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{ 79 comments… read them below or add one }

The Biz of Life October 12, 2010 at 7:46 am

Co-pays are designed to discourage frivolous visits to the doctor (at least that is what the insurance companies claim). I don’t think I’ve had an issue where the insurance didn’t at least pick up part of a prescription cost, but I’ve definitely never looked at my insurance company’s formulary. I wouldn’t even know to do that if I hadn’t read this article.


Kris October 12, 2010 at 2:07 pm

Biz, I know what you mean about high co-pays being used to discourage unnecessary doctor visits. Personally, I can think of a million other reasons I don’t want to go to the doctor, but I am sure it may be the deciding factor for some not to go. However, we are not doctors, we are just people, so how do you know when it is ‘unnecessary’ or not? Sure, little nose bleed, stay home. But how do you know when too much is too much? As I said, I wonder how many of these ‘unnecessary visits’ turned into expensive emergencies?

We fortunately have very few maintenance prescriptions. We just need the antibiotic here and there usually. However, even our asthma inhalers can be expensive. Some inhalers work better or are more compatible with certain patients, and I hate that you may not be able to use a drug that has worked for years just because it suddenly isn’t on the formulary.

I should probably stop commenting now so I can come up with a real Health Care proposal.


Nicole October 12, 2010 at 7:57 am

The insurance system in the US is messed up. Yes, copays are designed to discourage frivolous visits (as are coinsurance and deductibles), but they’re still not focused on getting the maximum amount of health for the minimum amount of dollars. The new health care bill will help some of that but will not fix all of the problems. Politically in the US it is infeasible, if not impossible, to truly fix health care.

HMOs, for all that they’re vilified, actually do a much better job on preventative care and making sure people follow through with medication etc, than PPOs, though they are definitely not perfect. David Cutler sees a future with an entire outside industry of patient managers springing up.

Different insurance companies negotiate with different prescription drug companies, so their formularies will be different. Doctors tend to prefer one drug over another without regard to what the patient’s formulary is. (Again, this is less of a problem with HMOs, since almost all patients are on the HMO’s formulary.) Sometimes pharmacist will make the switch for you.


Kris October 12, 2010 at 2:10 pm

Nicole – you are right, some doctors definitely push certain drugs. That is why I hate seeing pharmaceutical people in the waiting room, I just always envision secret deals going on in the back room.

In my most recent situation, it was late at night (my doctor’s office has late hours, but I was the last patient of the night) and the office was then closed when the pharmacist called to see if the prescription could be changed. Had I known what drugs were covered when I was in the office, I could have asked for something else that might still have worked instead of the Zithromax. But, my lack of knowledge hit me in the checking account unfortunately.


Roshawn @ Watson Inc October 12, 2010 at 11:27 am


You can definitely ask the pharmacist or call your insurance help desk directly to figure out what is covered underneath your plan. As a pharmacist, I feel it is very important to keep the lines of communication open. For example, there are some medications that do not cost very much at all that could be substituted (with your doctor’s permission) without going through your insurance at all. Additionally, you could ask for a price match to Walmart. It’s harder to find out the most economical way to treat yourself (without compromising effectiveness) if you’re not communicating though. Thus, I think your formulary idea is very good.


Kris October 12, 2010 at 2:11 pm

Roshawn – Yeah, it is good if you can get everyone talking. My appt was so late that there was nobody to talk to! I just miss the days when it wasn’t so complex and I could get my little prescription for 3 dollars.

Had I my formulary, I could have said ‘hey, Zithromax isn’t covered because I have the worst insurance ever, can we try this, this or this?’. It would save a ton of time and money.


Money Reasons October 12, 2010 at 9:04 pm

Sounds like a great tip!

My employer has great medical, but slowly, every year, it is getting worse and worse…

I haven’t run into a formulary problem yet, but if I do get bitten by it, I’ll do as you say!

Thanks, again great tip!!!


Kris October 13, 2010 at 4:33 pm

I just found out that our medical premiums are going up even more for next year. Great…

Don’t wait to get bitten by your prescription drugs- be prepared my friend!


Sandy L October 12, 2010 at 10:08 pm

Okay, I had no idea what a formulary was until I read your post. I officially learned something.

I feel for you. There’s nothing worse than feeling horrible and sitting in a stupid pharmacy when all you want to do is curl up in a ball and go to bed.

Sounds like we have the same insurance plan. Blue Cross PPO perhaps? We are having major changes in coverage next year. Either our current plan goes way up, or we can do a $5000 or $8000 deductible instead. Ouch.

In the past, when that’s happened, the pharmacist was able to get the covered drug filled instead of the prescribed one. I think they have some leeway on filling substitute meds. In fact, I think in some cases (like my mail order meds), they subsituted them automatically.


Kris October 13, 2010 at 4:34 pm

Sandy – So glad I could teach you something.

You are so right, rotting in a pharmacy chair is so awful. You just want to cry. Then you do cry when you have to pay for the whole thing out of pocket.

The pharmacist tried to change the drug, but the doctor’s office was closed unfortunately since it was so late. Lesson learned though, and it will not happen again.


Aloysa October 14, 2010 at 11:23 am

I am dreading any visit to a doc’s office because of the subsequent bill that will come later. I always try to buy generics if possible because their so much cheaper. Very good post!


Kris October 14, 2010 at 6:51 pm

Thanks Aloysa. Just don’t put off that visit because of the money! (Please)


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