Inconsistencies with Rx’s

I currently take Tresiba for my long lasting insulin (I’ve been back on MDI for about 18 months now).  And I started on my current insurance plan in March 2019.  I was paying $24.99 per month for a 30 day supply of my Tresiba- not bad at all so I never complained.  I also take Humalog but I’ll admit (#dontjudgeme) I stock piled it when I went off of my last insurance because it was covered at a good price.  So I haven’t had to fill a Humalog Rx yet on my new insurance … but back to my Tresiba story.

Several months ago I went to pick up my Rx as usual at the same pharmacy I’ve used for years (I had a bad experience with mail order for my insulin in the past so I choose to pick it up at the pharmacy) and they told me it would be $225 – Whaaa?  I told the pharmacist that I have been picking up this prescription for years and I have been paying $24.99, so surely something was wrong.  She said she didn’t know why, but said this is what insurance was charging and suggested that maybe I had been paying the wrong amount before.   And since I can’t go without it … I had to pay it. But I’ll be honest, I didn’t have the money that month.   My husband had recently lost his job unexpectedly and it was a HUGE hit that I wasn’t expecting. I was sick about it. But again, I had.no.choice.

So the next month I went back and it was $225 again but we had prepared for it even though we still didn’t technically have that much extra in the bank to spend – we knew I had to have it so we cut back on other “less necessary” things.

Then I went back the next month it was back to $24.99 – what is going on ??  I was so frustrated. I told her if it was truly supposed to be $24.99, why did they charge me so much the last 2 months ??? They had no explanation.  So I paid my $24.99 and went on my way.

I happen to have a background in HR and I work in the benefits world, so I am all too familiar with “the system” and how it works.  So I called our Rx vendor that my company uses and she did some digging around. She told me that … get this ….. the $225 was the 90 day copay.  And my dr had written my Rx for a 36 day supply, so they couldn’t charge the 30 day copay amount and were charging me the 90 day copay. That is IN-sane. I told her that I wasn’t getting 90 days worth, so I shouldn’t be paying for 90 days…. ? She agreed and apologized and said it was in the PBM’s arena.  *sigh*. She also said she was concerned that we may have “kicked an anthill” and that the actual copay was in fact supposed to be $75 and not the $24.99 that I had been paying. She was assuming that the pharmacy had taken it upon themselves to apply a coupon, hence the lower copay.

So I had to call my dr and have him send in a new Rx and to make sure that the box of 3 pens, which is what I had been using all along was in fact written for a 30 day supply, not 36, so they would charge me the right copay – whatever that ended up being.

Then I go back last month to pick it up …. and they said “That will be no charge, have a good evening!”  What?  Have you seen that Ikea commercial where the lady runs out to her car yelling, “Start the car! Start the car!” because she felt like she got such a good deal and wanted to get out of there quickly?  That’s how I felt. I thanked the person behind the counter and went on my merry way thinking surely someone had made a mistake and I wanted to leave before they figured it out.

Then whaddayaknow … I go back tonight to pick it up and they again said “That’ll be no charge, have a great night!”

I am so confused.   My pharmacy copays do not go toward my medical deductible. And they are based on a coinsurance so I expect that sometimes a copay will fluctuate a little here and there, based on drug cost (don’t even get me started on that … ) but this is ridiculous.    And no, I am NOT complaining about the zero copay. But what upsets me is all the times I paid $225 when I technically couldn’t and apparently most certainly should not have been paying that much.

Have I mentioned this is infuriating???    There has to be a better way to make sure that we can have our life support at an affordable cost.

About Shannon

I am a wife, a mommy, and a Type 1 diabetic (since '92.) I have had two successful pregnancies - one of which was with twins. I wear an insulin pump- - off and on since 1998, as well as the Dexcom CGM. I am not a medical professional, nor am I giving medical advice. I am just sharing my day to day stories of someone who lives with this disease every day. My ultimate goal is to raise awareness.
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2 Responses to Inconsistencies with Rx’s

  1. Rick Phillips says:

    Maybe there is something in the air. At the end of last year for 3 months I had no prescription co-pays. I called the pharmacy and said hey i owe you guys some money. So I called the PBM, no mistake. So was it the end of the plan year? Nope not that. the PMB had loaded the claims incorrectly. Three months no co-pay. My employer got stuck. Just do it correctly damn it.

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