Emergency Prep & Drugs

Flood, earthquake, tornado, hurricane, terrorist attack… The list of possible disasters isn’t very long.  That doesn’t mean it isn’t important to prepare.

One small line in most emergency preparation lists suggests including an extra month of prescription meds in your emergency kit.  I wondered idly how one might go about doing that, but when nobody in my family was regularly taking prescriptions it wasn’t an issue.  Now it is pertinent.

The problem isn’t with believing it’s a good idea to be prepared.  The problem is the difficulty of obtaining the extra month’s worth of meds.

1.  Insurance will not pay for early fills.  If you want to get an extra month, the cost will be entirely out-of-pocket.  That might not be a problem for one or two less expensive medications, but it’s a big deal if the cash price of your monthly trip to the pharmacy is nearly $3,000.

2.  Even if you pay cash so that you can have an extra month on hand, there’s still a problem.  Prescriptions allow a specific number of refills.  If you pay cash to get that extra month early, you run out of available refills at the pharmacy a month early.

I’ve jerry-rigged a solution.  I do not wait 30 days to refill my meds.  For a while now, I’ve refill my prescriptions every 27 days.  The first month, that got me three extra pills.  The second month, I added three more for a total of six extra pills.  The third month, I was up to nine extras, and so on.  For some weird reason, every now and then the insurance company says it’s too soon to refill and I’ve had to wait the full thirty, but this usually works.  Doing it this way, within a year, you’ll have a managed to stockpile an extra month’s worth of most prescriptions.

This doesn’t work with methotrexate, Enbrel, or anything else that’s filled for four weeks instead of one month.  Having skipped my Enbrel when I was sick, I know that when dealing with the stress of a disaster, I don’t want to be without that particular prescription.  However, since I was already well into the process of trying to accumulate an extra month’s worth for my emergency kit when I got sick, I filled the prescription at the regular time anyhow (despite not being out).

It’s a good thing I did!

Add insurance change to the list of potential emergencies

They had the audacity to send out a letter last month with instructions that we should refill prescriptions before the end of the month (on our old insurance) because it would take a while to get everyone into the new insurer’s computer system, and it probably wouldn’t be possible for the pharmacy to verify coverage for a few days.  I could picture getting laughed out of the pharmacy if I tried that, so didn’t bother.

Next the insurer said they should have everyone processed by the 10th, but we could just pay cash and then submit a request for reimbursement.  I didn’t think that would be needed, since I last filled on the 10th and would just be stretching things out to the full thirty days.  Unfortunately, the 10th came and went without new insurance cards.  My dear husband, concerned that I wouldn’t be able to get my prescriptions, was duly impressed when I said that I supposed this counted as an emergency, and explained my strategy to him as I dug into my emergency supply.

It was nice to be prepared.  It wasn’t nice to need it, but it worked out.  I had to pay cash to get my mtx last week, because there’s no extra stash on that one.  The rest of my prescriptions, though, I’ve been able to take normally, without the stress of wondering when those insurance cards are going to show up.  The tiny effort needed to be prepared was well worth it.

Do you include a month’s worth of prescriptions in your emergency kit?

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Pharmacy

There’s quite the discussion going on in the comments section of a post over on KevinMD.  A gross simplification of the issue is that a few pharmacists and pharmacy techs took offense to my suggestion that it’s unreasonable to charge $45 for a prescription if it’s possible to make a profit charging $5 for it.

What the pharmacists commenting on that post have said contradicts what my insurance company has told me, as well as what my pharmacist has told me when I’ve asked questions.  Summarizing the information provided by a few different commentors, then:

It turns out that things aren’t nearly as straightforward as they could be.  Insurance negotiates a contract with physicians, but at the pharmacy there isn’t quite as much negotiation power.  Pharmacies are in the position (even more than doctors) of having to take whatever amount insurers offer, or not accepting insurance at all (in which case patients will go elsewhere).

One point that multiple people have made is that it costs a pharmacy $7-12 to fill a bottle, plus the cost of the drug, regardless of which medication is prescribed.  In addition to paying for the medications that it sells, pharmacies must purchase prescription bottles and labels, pay labor costs to employees, and cover the costs of doing business such as facilities rental/mortgage, electricity, computers, refrigerators, etc.  Those stores that have $4 rxlists are losing $3-8 on every one of those $4 prescription they fill.  The stores make a profit on other items to cover the losses of their pharmacies (which are there simply as a convenience to get customers in the door).  That’s not something that standalone pharmacies are able to do.

As to pricing, usually companies buy goods at wholesale and sell them at retail.  One of the pharmacists who commented on the linked post says that the pharmacy world is different, and that what they call “average wholesale cost” is really suggested retail price, and that what the pharmacy pays for drugs is called ACQ (acquisition cost).  AWP is usually 33% above ACQ.

If I follow this, then AWC will never be less than the $7-12 it costs a pharmacy to fill a bottle (from here on in, I’ll use $10 as an average).  If pharmacies could charge AWC, then they’d be satisfied that they were getting a fair deal.

The problem arises because of insurance.  Insurers know that there’s a 33% markup between ACQ and AWP, and decided that’s too much.  Insurers knock 25-30% off AWP, leaving 3-8% markup, then tack on a dispensing fee.  The dispensing fee, however, doesn’t come close to covering the true costs of dispensing a drug, which means that the 3-8% markup is not profit, but goes to cover dispensing costs.

Insurers, according to the pharmacists, usually pay around $1.50 as a dispensing fee.  It might be as low as fifty cents or as much as two dollars, but it doesn’t approach the $10 that it costs a pharmacy to fill a prescription.

There’s a twist to that dispensing fee, too.  Some insurers will only pay a dispensing fee every thirty days.  People aren’t supposed to let their meds run completely out before getting refills, so I can see where that’s a huge problem.  If my insurer does this, the pharmacy only gets a ninety-nine cent dispensing fee every-other-month, because I don’t wait until I’m out to get my refills.

Another  pharmacist indicated that AWC only covers the drugs, and the 33% above ACQ doesn’t cover dispensing costs, in which case $10 needs to be added in order for the pharmacy to be making a reasonable profit.  If AWC=ACQ+33%, then what is the 33% for if it’s not supposed to cover labor, materials, and profit?  I think that’s where I’m still a little bit confused.

What it boils down to is that the insurer tells the pharmacy how much it will pay, and also tells the pharmacy how much to charge the patient (as a copay); neither of those numbers has anything to do with the “cash price.”  The quoted “cash price” means nothing if you have prescription coverage on your insurance plan.

A Good Change

Walking, wearing my wedding ring, and being able to swallow easily are things that I used to take for granted.  No more.  Thanks to an immune system that turned on me, I realize just how fragile life is, and how quickly things can change.

With a speedy diagnosis, which led to multiple prescriptions, my swelling is down.  I can wear my rings again (most of the time).  I can swallow and don’t feel like I’m choking.  I can get out of bed in the morning without yelping in pain.  The results of those Disease Modifying Anti-Rheumatic Drugs are fantastic!

Every morning I eat breakfast and take my pills (four of them).  Mid-day I’m not hungry, but grab a bite to eat so that I can take my pills (four more).  Then in the evening, I fix supper and take five more pills.  As if that’s not enough, I take a omeprazole at bedtime to (I hope) prevent all those other pills from eating a hole in my stomach.

Tuesdays are special.  When I get up in the morning, I inject my Enbrel.  At bedtime I swallow my eight methotrexate pills, then sleep through the dizzying side-effects.  Those bonus meds on Tuesdays have made a huge difference in how I can function in my life.

Those drugs don’t grow on trees, though.  I can’t just walk out to the garden for them like I can apples or sage.  Every month I have to journey to the pharmacy.  Every month I would come home and write a rant about how aggravating it was to deal with my pharmacy.  Some of those rants I posted, some I deleted, and some still sit in my drafts folder.  I would never do business with any other company that frustrated me as much as the pharmacy did, but the meds help a lot so I figured that dealing with the pharmacy was part of the price I had to pay to feel better.

The more I thought about it, though, I decided that I didn’t have to be stuck with that particular pharmacy.  There are many others.  Maybe another one would be better.  I started looking around, observing pharmacies in the area.  I talked to friends to find out where they get their prescriptions, and their reasons for liking/disliking their pharmacy of choice.  I even asked one of the pharmacist bloggers for tips (thanks PC).

A few months ago I finally made the switch.  What a difference!

  • 21 miles closer to my house (but nowhere near my doctor’s office)
  • refills can be ordered online
  • two of the prescriptions cost less than at the old pharmacy
  • they remember to send the Enbrel charge to the program that reduces my co-pay
  • they promptly contact my doctor and refill my meds (instead of losing the faxed authorization from my rheumy)
  • my meds are ready and accurate when I pick them up

It’s amazing to have this work the way it should.  When I have five days left on my prescriptions, I log on to the pharmacy’s website to order refills.  A day or two later I go pick them up.  Everything is accurate.  No hassles.

I should have changed a long time ago.