Why our American Medical System is broken.

Maura takes Trileptal for her seizures.  It works well.  Everyone has been happy with it.

Maura tried the generic a few years ago.  And by “tried it”, I mean we submitted our prescription for Trileptal to the Medco Overlords (Medco is a mail order prescription company that we were required to use for any ongoing prescriptions) and received a box of generic stuff instead.

So we tried it.

Because we had no choice.

It caused her to be moody.  Really moody.  To the point that her teachers offered to write letters attesting to how moody it made her.  My normally happy-go-lucky girl was pitching fits and screaming over everything.  She wasn’t easy to live with.

We got Medco to allow us to go back to Trileptal, after our doctor wrote a note stating Maura needed to be on the Trileptal.  They charged us the cost difference of the generic, something like $25-30 at the time.  The Trileptal full price, back in 2010, was something like $120 or so.

When we moved to Ireland, we had to pay out of pocket for it for a couple months.  It cost us 80 euro ($106 by today’s exchange rate).  I remember being surprised that it was cheaper in Ireland.  But then we were able to get Maura on one of the social welfare programs that covers prescriptions, the Long Term Illness benefit, and didn’t have to pay a dime.  It was awesome.

(Note – Ireland has a program that if ANY family pays more than like 135 euro per month in prescriptions, you can be reimbursed any amount after that.  So no family will ever pay more than 135 euros a month in prescriptions.)

Now we’re back in the States, noted world-wide for its awesome health care providers, innovative techniques, abilities to cure diseases other countries are still struggling with.  I went to the pediatrician with Maura, explained our dependence on Trileptal and our need for a neurologist.    She started the referral process for a neurologist and gave us a 2 month prescription for Trileptal to tide us over.

I went to fill that prescription today, with my handy dandy insurance card, the one that swore it covered 100% of preventive drugs.  I left the prescription with the nice woman who assured me a new bottle would be waiting for us the next afternoon, which was great because with all my school flurries, I had put this off to the last minute.  I only have a couple days worth left.

And then the pharmacy called.

The nice woman told me that the way the doctor wrote it, she can’t do a 30 day supply because that’s not how it’s dispensed.  The bottle would only have 20.8 days worth in each.  If I wanted, she could do a 40 day supply, or two bottles.  That was good, great, thanks.

She said “Okay then, I will fill that prescription for Trileptal generic oral suspension.  The copay will be $60.”

I said great, hung up…and went…

Wait.

Did she say generic?

I called back.  Got another nice woman,  Explained what I thought I heard and was told that yes, they were ordering the generic.  Why, did I want the name brand?

Yes please.

Okay, name brand ordered and will be ready for the next day.

Awesome.

Except now the whole “copay” thing was beginning to make me scratch my head.  I didn’t think we’d have copays for this.  I pull out the handy folder, easy explanation guide.

“Preventive drugs are covered at 100%.”

What the heck?

Okay, it’s new insurance, maybe I’m missing something….

And my phone rings…

It’s the pharmacy….

The nice lady calls to state that since I want the name brand, she can only disperse one bottle of that at a time, so I can only get the 20.8 day supply.

*sigh*

Fine.  Whatever.  Maura needs this.

Then she tells me that the copay will be $220.

TWO HUNDRED AND TWENTY US DOLLARS.

TWO HUNDRED AND TWENTY FECKING DOLLARS!

For something I can get for half the cost in Ireland.

I said “WHAT? $220!  For the copay?  How much is it full price?”

$300.

“IT’S MORE THAN DOUBLED THE COST SINCE 2010?”

“I don’t know ma’am.  But the copay is so high because they penalize you for choosing the name brand instead of the generic.” (I am paraphrasing…except for the “penalize” part.  She used that word.)

Yes, because I want the drug that I know works on my daughter well without side effects, the medication she’s been using faithfully for half her life, I must be penalized.  And pay twice as much for a COPAY as I would to buy it full price in Ireland.

I looked at my benefits book.  “But I shouldn’t even be paying a copay on the generic!  WTH?”

The poor woman explained that that’s how they were billed when they put our info into the insurance system.  She offered to hold off while I worked things out, but Maura NEEDS the medicine.  We can’t just skip a few days.  I calmed down enough to stop shouting “TWO HUNDRED AND TWENTY DOLLARS!” into the woman’s ear, enough to let her know I wasn’t angry with her and got off the phone.

I did go off on Facebook.  Where a friend told me to call Costco, that they often had better prices.

So I call Costco.

Who said out of pocket, the Trileptal would be $240. He couldn’t give me an estimate with insurance without trying to bill them, and I mentioned the $220 copay.

He said “For a COPAY?”

Yes, I’m not the only one surprised by this.

$220.

For a copay.

For a twenty day supply of meds.

That’s $11 a dose.

For medication that’s often prescribed to people with seizure disorders.

BUT WAIT!  THERE’S MORE!

I looked over the bit of paperwork we do have for the insurance (because all benefits can be explained in detail online, except I’m not able to look that up as I haven’t been formally allowed on the account)….and I read this –

“See complete Preventive Drug List in the Resources section of this guide.”

Okay.  Turn to the list.

Guess what’s NOT a Preventive Drug listed?

Seizure medications.

ANY of them.

I can get drugs to prevent conception.  I can get drugs to prevent hypertension.  I can get drugs to prevent nausea and dizziness.  I can get drugs to prevent gout.

GOUT!

I can even get colonoscopy preps.

But drugs to prevent seizures aren’t consider preventive.

Four different classes of drugs to treat hypertension?  Sure.  Come and get them.

Seizures?  HA!

Thank God they cover ulcer  medications, because I’m about to develop one.

There is something really wrong with our health care system when a medication can more than double in price in 2 1/2 years, yet remain lower than before in a less affluent European country.  Ireland may not have had the best health care, but at least I could afford it.  And when it was deemed “too much”, the government was actually helpful.  Health care wasn’t seen as a way to get rich.

 

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