Can You Afford Mental Illness?

June 30, 2011 Angela McClanahan

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. pill1

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.

APA Reference
McClanahan, A. (2011, June 30). Can You Afford Mental Illness?, HealthyPlace. Retrieved on 2024, July 24 from

Author: Angela McClanahan

ms sucidalnow
July, 2 2011 at 7:10 pm

Funny how insurance companies control our lifes, our goverment and our doctors. Supposedly we plaxe persons into polital positions to contribute to the best of our country. Insurance has been a topic for yrars without a solution. I have one for them.
Just as all US citizens are required to have social security cards, and our goverment or social security has access to them. Why can't they look at what a person earns and require that whay they be charged for insurance, it's what they do for taxes. Naturally your high income earning people would be against that, but how many mid to low income classes are their in ratio to the wealthy, How did the wealthy get so wealthy, did they send their businesses overseas violating every labor law in the US to get rich.richer, then send the products to the US where they still make a larger profit, however if the Ameicans no longer have jobs b/c theirr in other ccuteries how are they to work and pay for insurance, homes, meds cars, etc. It all stinks, yet all you need to get pray out of school is one or two people why can't we stand up to goverment.

Brooke S
July, 1 2011 at 3:20 pm

The requirement to take a generic and fail before being allowed to take a brand medication always gets me. What do they define as an antidepressant failure? An expensive hospitalization? Suicide? Well, I guess if that happened they wouldn't have to pay for the antidepressant now would they?

Sara Anderson
July, 1 2011 at 1:31 pm

GREAT article! I have some of the same "issues" with the prescription drug coverage we have and actually wrote a blog post about it. My husband is unable to work, though we are very fortunate that my employer offers a prescription plan. Though, since we are a family of 5 on only one income the coverage that the prescription plan provides can really stretch our budget. After a recent hospitalization and changes to medications he was already on his monthly co-pay jumped from $50 to $100. That was only one of the 12 medications he takes. It can be VERY overwhelming at times, especially considering that many of the psychiatric drugs he has been on are not "generic". Question is, does anyone hear our cry for an ease on prescription costs?
Sara Anderson

Leave a reply