“Prescription Drugs Are Too Damn High!
Change in prescription drug coverage leaves employees without medicine
Editor’s Note: This is an inflammatory, one sided article presenting only one side of a growing health care cost driver that’s bankrupting group health insurance plans across the country. Even the TRS ActiveCare government health plan, as big as it is, can no longer afford to continue to pay high cost specialty drugs. The good news is there are solutions in plain sight for plan sponsors to seize towards taking back control of their health care spend.
Special to The Henderson News – Oct 24, 2023 Updated Oct 24, 2023
A statewide decision by the organization that provides health insurance for both school employees and retired Texas educators, has forced some local school district employees to abandon their beloved hometown pharmacies and caused serious problems for others with life-sustaining prescriptions. The problem stems from a recent change in drug coverage under Texas’ Teacher Retirement System (or TRS) which provides benefits to school employees, retirees and their families.
“Starting this year, we’re required to use Express Scripts for our prescription medications,” said Assistant Superintendent of Personnel and Policy Amanda Wallace. “Unfortunately, our independent hometown pharmacies like Strong-Hurt Pharmacy which have been around for a long time, are now not in-network which means the cost of many drugs is likely to go way up.”
Mindee Mata says she spent more than 30 hours on the phone with Express Scripts and her doctor trying to get medication approved for her 15-year-old daughter who had Tuberous sclerosis Complex (or TSC).
“If my daughter misses her medication, she must be care-flighted to an ICU,” says Mata, who says Express Scripts denied covering two of her medications which keep her alive. “Our coverage changed on September 1st and we found out on September 2nd when I tried to refill her prescription. We had no warning.”
The lack of notification from Express Scripts is surprising since Mata is the Director of Business Operations at West Rusk ISD and oversees benefits for school employees. “I’ve had several employees upset or had problems with the changes,” said Mata. “All I can tell them is, ‘I’m just as mad as you’. [Express Scripts] is not willing to work with you at all. They just don’t care.”
Mata says the company initially denied coverage for the prescription, which helps control seizures, and would not approve the secondary coverage, leaving Mata to pay the full cost of $49,000 per month. After several phone calls back and forth, Express Scripts agreed to partially cover the drug if she bought it through Accredo, a specialty pharmacy which is a subsidiary of Express Scripts. However, the co-pay would still be $16,000 per month. It was only after several more hours of conversations between the company and her doctor that the pharmacy agreed to work with the secondary coverage reducing the cost to a reasonable amount and only then could she schedule it for delivery.
Now Mata is working to get approval for the second drug approved which limits tumor growth in her daughter’s body. The medicine costs $128,000 per month.
“When we first lost coverage, I didn’t sleep for a week,” says Mata. “Her seizures had been relatively controlled, but with the threat of running out of medicine, I had to get a new seizure plan, collect new protocols for CareFlite nurses and prepare–it is all incredibly stressful.”
And Mata’s not the only one. Several employees at Henderson ISD have had difficult times renewing or moving their prescriptions, many of them from hometown pharmacies they’ve used for decades.
HISD administrators reached out to local pharmacy owners and operators in an attempt to find a way for employees to continue supporting local businesses, but so far no solution has been found.
“We’re not just passionate about supporting our employees–we also want to support our local businesses, “ said Wallace, “These companies–like our independent pharmacies–are owned by our families and neighbors. Many of our students work at these businesses and they support our football team, our band and our cheerleaders all year long. Our employees have been their customers for decades and suddenly, this change has closed the door on them. I’m disappointed to see the state’s actions will prevent these local business owners from continuing to serve our teachers.”
● TRS has selected Express Scripts, based in St. Louis, MO, to manage prescription drug coverage for Texas’s teachers and retired teachers.
● One West Rusk ISD employee was facing the prospect of paying $177,000 per month for life-sustaining medication for her daughter after Express Scripts initially denied coverage.
● Many teachers and retirees have had current prescriptions denied since the September 1, 2023 change, leading to gaps of days or weeks in medication supplies.
● Many locally-owned, hometown pharmacies are no longer “in-network” unless they agree to offer prescriptions well below cost, sometimes as much as 25% below cost.