Can You Afford Mental Illness?

I had intended to spout on a completely different topic today, but I'll be honest--this insurance business has, to coin a phrase, my dander up. Judging from the majority of comments I've received, I'm not alone.

Last night I began reviewing the thick folder of information my husband received at yesterday's meeting concerning the new health plan through his employer. I was immediately disappointed to see they'd selected the "high deductible" plan--$2,500 per year, per person. The psych group Bob has been seeing for the past three years is, thankfully, a "preferred provider" under this plan. Our office visits will, therefore (as long as they are kept to the 15-minute "med check" limit), be $40.

Overall, pretty much the same as our last plan through this insurer (that we had through my former employer).

Then I took a look at the prescription coverage. I believe it was then my head began to spin like Linda Blair's.

This plan features the "three tier" system to determine out-of-pocket cost for medication. As explained in the Prescription Drug List Introduction, Tier 1 includes the generics for the low, low price of $12.

Should a patient decide to buck the system and go with a name-brand drug, they find themselves in either Tier 2 or 3. The cost for a Tier 2? $50--more than four times the cost of generic. Dare to request a Tier 3 drug? That'll set you back $70.

Come again?

Yes, $70. According to the Introduction, the formulary is managed by a committee "composed of practicing doctors and pharmacists within the Kansas City area. Quarterly meetings are held to evaluate new drug therapies and review drug utilization issues." Tier 3 drugs "includes medications with an available generic equivalent and new drugs that are being reviewed."

So...three of Bob's current scripts are Tier 1. Seroquel is Tier 2. Of course, it's now yours truly who is bleeding the family coffers--my 225mg venlafaxine tablets are Tier 3.

Really? Because I was under the impression venlafaxine IS the generic equivalent of Effexor. But there it is, in the highest copay category, with no readily available explanation.

But wait--there's more.

...(A)s new products are released and post-marketing information on existing therapies becomes available, changes in status (Tier 2 to Tier 3) may occur. The committee may also implement prior authorization or other utilization management processes as deemed necessary.

Uh-huh. Deemed necessary by who? An insurance executive concerned about the bottom line? I wonder if these committee members serve voluntarily, or if they're compensated for their efforts?

And yes, it's spelled out on page 2 of the formulary that anti-depressant seekers will be required to try and fail a generic before a brand name medication will be covered. (Lucky for me and Bob, we've already taken--and failed--just about everything under the sun.)

I guess I'm supposed to count my blessings and be grateful for any drug coverage. After all, under this regime, drugs to treat a simple old toenail fungus (without a more serious underlying condition) are strictly verboten.

Good thing I don't have that to worry about.