I'm PISSED!!..need a little help from the smart folks here...

[one_voice]

Here's the situation:

I have United Healthcare (assholes!)....

A few months ago I went to get my prescription filled (lyrica) and the pharmacist told me it was denied by the ins. company so I came home and called. U.H.C. tells me the denied it because they were no longer covering it at my local pharmacy they wanted me to either go with a different (generic for another drug which I'm allergic to) or mail order for the lyrica.

So after two months of going back and forth; multiple calls to my doctors office, they finally get my prescription mailed out to me.

During this time, they told me 4 different stories--what I needed from my doctor--lost multiple faxed rx's--and took a week once they received the prior authorization to get the actual prescription from my doctor--they had to do that. Thankfully I had extra meds here or I would have been without my medication for two months.

They did an emergency over-ride at the first denial. It's a long story and frustrating.

So, Friday evening I went to pick up my husband's prescription (Januvia) and again; denied. I came home and called. Same reason, no longer covered at the local pharmacy. They want him to use a different medication (for local filling) or mail order to continue with the Januvia.

This is a drug for diabetes. It was 6:45 on a Friday night, they (U.H.C.) go home for the weekend at 7. I was PISSED!

Apparently, this is their policy. No letter, no phone call, no email, to let you know they've changed how they will cover/pay for a particular drug. They just deny.

They lady I spoke to said we left a note in the system for the pharmacist to tell you to call us---I told them it's not the pharmacists responsibility it's yours. I pay YOU a SHIT load of money every month. YOU don't do anything for FREE. What don't you understand about that?

My husband also takes a medication for his heart. What if they do that with that medication?

I'm beyond pissed. To say I yelled would be an understatement. These two issues are only two of the things I've had happen since we switched to them in Jan. It's been hell dealing with them.

I chose them when we had our enrollment last year--I was with Blue Cross Blue Shield--never an issue with them---but I went with United Health Care because they seem to have better coverage. I'm stuck with them until re-enrollment.

I'm contacting the benefits persons at my husbands job, but there has to be more I can do about this. This is dangerous. If I had waited till 8 to pick up his prescription, I would have been shit out of luck till Monday. Even with an emergency over ride they have no idea about my situation. Maybe I had someone take me to the pharmacy because I don't have a car or use public transportation. It's completely unacceptable. It's irresponsible.

I worked for both Cigna and Met and we didn't do shit like this. The insured was treated like a valued customer. I would have lost my job on the spot if I did some of the crap these people pulled.

Shouldn't they have to send a letter or something? It's probably a cost saving measure on their part, they save on paper a stamp etc. By denying the drug, they get you to call and tell you what you have to do.

They use OptumRx as their mail order and they are HORRIBLE!

Sorry for the ramble...but I'm really pissed. I'm a fucking paying customer...what the hell?!?!

[hedgehog]

1. Perhaps a call to your state's insurance board ----

or the local tv station is in order!

[one_voice]

2. I thought about my state's insurance board...

I think I will do that today. I wasn't sure if that's who I could call for something like this.

I did threaten them with the Insurance Commissioner and after I hung up thought 'oh man I hope that's the right person/agency'..lol.

[SharonAnn]

65. You sign up for a year and can't change anything, but they can change any services at any time.

This is one of the biggest scams that this "one-year contract" is. You guarantee to pay them for a year and they guarantee nothing.

It's been this way for a very long time, more than 20 years, at least. They've just gotten more and more aggressive about gouging every penny they can for profit while providing less and less because that's a cost to them.

Their lobbies are working effectively.

[xtraxritical]

72. It's because the insurance company's think "single payer" is on the horizon.

[Demo_Chris]

3. No answer, but thanks to Obamacare you have no choice but to remain their customer

Sure, you could change to a different company that will do the same, but no matter how bad it gets you are no longer legally allowed to keep your money.

[one_voice]

5. I was wondering how long it would take...

actually it has nothing to do with Obamacare...

I was fine with Blue Cross and will go back to them in October when we re-enroll.

Please don't use my thread to shit on the President. This is a serious question about medication. A diabetic medication that could have serious consequences if it's not taken.

I asked for help from the smart people on DU. Not smart assed answers from people that look to take any and all opportunities to shit on the prez.

[Aristus]

24. Well said, once_voice. Bravo!

It's like a reflex with some people: "Well, ya know, it'z cuzza ObamaCare!"

Well done.

[calimary]

50. AMEN.

I'm sick and tired of people dumping on Obama first. If that's where they reflexively go, then they're getting their information from Pox Noise and various media wannabes, or from the limbaugh/breitbart clones.

[chillfactor]

29. GREAT COMEBACK!

There are just asshats...so quick to sign on with absolute nonsense and shit on the President!

I am so sorry to hear about all your problems with your insurance company. Insurance companies so readily take our money and give us crapola responses and coverage in return.

[evilhime]

45. Few to tide you over

We had that one time and the pharmacist gave us a few pills to tide us over until we could either resolve the issue or get delivery from MedCo (that's who BC used). Sucks when they do that though . . . insurance companies are always the bad guys IMO... When we had trouble with United, the benefits manager resolved them for us with their rep... hope you get similar help.

[solara]

46. Here! Here!

So sorry you are going through this. But I am uninsured right now and learning from your misfortune. I hope it works out in your favor I really do.. Thank you

[Ms. Toad]

55. Thank you.

I am so sick of things which have nothing to do with the ACA receiving the knee jerk response "Obamacare = evil"

It isn't perfect - but it has nothing to do with most of the things it is being blamed for.

[VOX]

81. THANK YOU!

Sorry for the dangerous hassle you're having, but thanks for being a good Democrat.

[Hekate]

85. Thank you, one_voice. Only suggestion I have at the moment is...

... to contact your employer's benefits office and tell them your experiences with this company. Put it in writing (on paper). In detail. Indicate the remedy you seek. CC the Insurance Commissioner (was that the entity someone else mentioned?). CC anyone else you can think of along the food chain, such as a state or local watchdog group.

Best of luck to you and your husband getting this sorted out.

[Cha]

106. thank you, one_voice.. you did say you wanted to hear from "the smart people"!

Good Luck with your problems gettting your insurance company straightened out until you go back to Blue Cross. It's very serious.

[Raine1967]

112. ((hugs)) one_voice after all that -- that you need to respond to this bullpuckey...

proves to me once again that you are amazing.

There has to be something in the PP &ACA act that is supposed to prevent this.

[Warpy]

56. This is not the case, Slick, in fact it's a blatant lie

I would gently advise you to avoid whatever you've been getting your "news" from and read the plan, itself.

[Demo_Chris]

59. Are you seriously suggesting there is no mandate in Obamacare? nt

[Warpy]

62. Not the way you think it is.

[Demo_Chris]

68. Sweet, a mindreader! That's one seriously awesome gift! Use your powers for good.

[Skittles]

91. so DO TELL US

how would YOU like the healthcare mess in America fixed? What would be YOUR solution?????

[Demo_Chris]

94. Single payer. Period.

For-profit healthcare, as a function of the profit requirement, automatically adds to the cost of healthcare. For example, insurance companies earn profits by collecting more from policy holders than those policy holders will cost. The spread is their margin. The more they charge and the less they pay out, the more they earn. They serve NO FUNCTION beyond this, they don't help the patient or the doctor, they add nothing to care, they are parasites who exist on the blood extracted from their victims.

Obamacare removes the only protection people have. Under Obamacare it no longer matters how poor their service is, it doesn't matter how insulting they are or how badly they treat you, it doesn't matter how little they pay out, it doesn't matter how worthless the policy actually is or how little it covers. It doesn't even matter if you no longer want to do business with them. No matter what they do, you have to give them your money. They are now, thanks to Obamacare, the ONLY special protected industry in America. It's the law. You will do business with these private parasite companies or the government will come after you.

[LanternWaste]

82. I'm afraid I don't understand how the health care reform either initiated this particular problem...

I'm afraid I don't understand how the health care reform either initiated this particular problem, or maintained it...

And if it did neither, then it seems (at best) irrelevant and (at worst) childlike petulance on your part.

[Hekate]

83. I was targeted by a push-poll on Sunday that was more subtle than your post

And that's saying something.

[dixiegrrrrl]

4. I am concerned about the trend...

The drugs they want your to mail order..
do they cost the same as if you bought them in pharmacy?
How fast does the turn around take after you mail order?
And is it easier for you to just drop the meds part of your insurance and pay out of pocket?

I am trying to figure out how insurance benefits by cutting out the pharmacy.
Maybe a talk with your pharnacist will reveal something.

[one_voice]

6. My lyrica was a little...

cheaper via mail order.

My husband used to get one of his heart meds through Medco and it was cheaper.

As for turn around time, Medco was great, at least for me. They'd send it out and bill me later. I don't know what other people's experiences were like.

As for this OptumRx so it's not looking too good...

But I will talk to my pharmacist...I'm sure it does save the insurance company.

[dixiegrrrrl]

10. the other trend I am hearing is that insurance payouts

are not lump sum.
Have read of incidents where people try to collect on their life insurance and are told they have to accept an annuity instead of a lump sum payout.

In any case, glad to hear your info, for future reference.

[Ms. Toad]

57. Life insurance is unrelated to health insurance -

but whether the payout is an annuity or lump sum will depend on the insurance contract. It can't be imposed at the time of death.

[Warpy]

58. They're trying to discourage the use of brand name, on patent drugs

by making sick people jump through multiple hoops to get them.

While generics might be as good for some people, in cases like the OP where allergies exist, the drug should simply have been approved at the local pharmacy. Instead, some officious bean counter got all rigid.

This is wrong. It's also insane.

[Hoyt]

61. Usually it is cheaper, and you often save on copays.

It is really the way to go.


Truthfully, traditional Medicare would be smart to get into drug formularies, generics, bulk negotiations, designated pharmacies, etc. Not only are for profit providers opposed, but too many of us aren't willing to participate in ways that hold costs in check.

[Hekate]

86. Not all generics are created equal. One made me really, really sick. Now, every year...

... I have to reprint the original letter I sent my health insurer, get my doctor to sign a form saying that the brand name is medically necessary in this case, and generally refuse to accept the generic form of this one drug. And, to put the frosting on the cake, it costs a whole lot more.

Just sayin' there has to be some flexibility built into the plan.

Cheers.

[one_voice]

95. Different buffers...

I had a doctor tell me that he never ordered generics because sometimes the buffers and such weren't the same and caused people to get sick. I guess it could be the same for different generics too.

Big Pharma is a racket. Don't even get me started on that...

[Hekate]

96. Also, the extended release formula stays on patent while the rest of the med goes generic

So the manufacturer of the "totally the same, I swear" generic just sort of throws something together and calls it "extended release"-- and the FDA doesn't check it out, because the manufacturer is allowed to self-report.

My anti-depressant sent me on a roller coaster I will not even try to describe here.

[DCKit]

7. U.H. are scumbags.

My Mom had a policy with them through AARP, and we canceled it... but they kept taking her money for another three months afterward.

Since I wrote and mailed the letter on her behalf, I know that it got done before the deadline. But they lied about it anyway.

When it was all said and done, they still got about $310 out of her, and it was incredibly stressful for her.

Since AARP was of absolutely no use, she cancelled that membership as well.

[dixiegrrrrl]

12. AARP is like the Hotel California..you can never leave.

I cancelled my membership in 1998, moved to 2 different addresses since then, and STILL get begging letters from them, got one last week.
Nothing stops them from sending me junk mail.

[solara]

47. I am not even a member of AARP and

they have been sending me their crap for several years now.. I guess they were guessing about my age

Glad to know you don't die if you don't join AARP

[dixiegrrrrl]

48. Kinda scary, but they have a way of knowing when your turn 50.

Apparently the DMV s sell their lists..isn't that nice?

[solara]

52. It's pretty scary actually

It's so good to get some real information about that organization. I have always been wary of "joining" clubs and such.. so I am glad I held off. thanks much for your perspective.

[cui bono]

70. There's an alternative, I don't remember the organization's name though.

Hopefully someone who knows it will chime in. I don't like AARP from what I've read about them.

[solara]

87. Nice to know there is an alternative

because it all sounds good on paper... I just don't like the over-all vibe.. especially now that people have shared their experiences. AARP sounds almost as bad as the insurance companies.

[Scuba]

8. UHC should be facing RICO charges for this, which is one of thousdands of examples.

[cui bono]

9. What difference does it make to them if you get it locally or via mail order?

Can't see how it makes paperwork any easier for them. Are they getting a kickback somehow? Are they involved in the mail order business? I don't get it.

[one_voice]

14. Honsetly I don't know...

they didn't tell me. Only that they'll only cover certain drugs at the local pharmacy. But now that you've asked that question, next time I call--which will probably be today to set up mail order--I will be asking.

[jeff47]

19. Price.

The local pharmacies charge the insurance company more. The mail-order pharmacy charges the insurance company less.

[Ms. Toad]

63. And often the insurance company farms out

managing all prescriptions (mail order and pharmacy) to a mail order outfit. Medical Mutual farms theirs out to Express scripts.

So - mail order pharmacies have motivation to pull more of it in house since it is cheaper for them to process things in house than to do the paperwork associated with paying someone else to fill a prescription.

[sharp_stick]

11. Because it's company sponsored

your company, or your husbands company, should be the one contacting you regarding changes in insurance. A lot of times these changes are blatant money savings so they'll fine print it to try not to look like total assholes. In truth when you find out about the changes it just makes it even more aggravating.

During the last enrollment I wonder if they had a small print notice about switching to a mail order system? I hate that kind of BS with a passion, by the time you notice it you're screwed and in the system. UHC pharmacy consolidated with OptumRx at the end of 2012 pretty much putting you in the bind you're in.

Our company switched our (CVS Caremark) prescription plan to a "co-insurance scheme" where instead of paying $30 for a 90 day supply we'd now have to pay at least $30 and up to $200 (based on a 50% of retail) for a 90 day supply.

I take a medication that costs well over that and would have had one hell of a time coming up with a spare $800/year. Luckily my wife read the fine print and I was able to get in on a copay assistance program with the drug company.

You are unfortunately probably stuck until re-enrollment. My suggestion would be to switch all of your medications to renewing mail order if you can. Make sure your Doc has 90 day prescriptions listed with OptumRx each with at least one preferably 2 renewals giving you 9 months of medication without need of a doctors contact. If you can time them so that you can renew them all at once with the Doc that will also make it a little less troublesome.

And a suggestion from a medical professional. Try to never let yourself be caught without at least 7 days of vital medication (21 days preferred for non regulated) before getting your refills in order.

[one_voice]

13. I will go back and look over the paper work...

I don't mind the mail order, what I mind is they denial with no notification.

We enrolled in October of 2012. My lyrica was $60 at the local pharmacy, I'm paying $150 for 3 months now.

It would be nice if we got a list of meds that were going to go to mail order or needed to be switched to another med (and a list of what meds were acceptable) and when that was going to happen. So we could take care of it.

Also would be nice if they had competent people working that could answer questions and get the switch done in a timely manner.

I usually do get it filled a week in advance but brain farted on this.

They lyrica taking as long as it did was the fault of UHC and OptumRx. Friggin' idiots.

Thanks for the info, it's helpful. I will know what to ask when I contact the benefits person at my husbands job.

[sharp_stick]

21. Check with your doc about this

https://www.lyrica.com/Lyrica_Copay_Activation.

Your doc might also be a good source to ask about other drug copay assistance programs. If he/she doesn't know go straight to the company websites. A lot of them will waive or reduce your copay just so you keep using their medications.

I don't know about the Pfizer plans but if it works like mine they might be able to knock your copay down quite a bit.

I found out about our switch to mail order the same way as you. I always had a prescription filled at the local store but all of a sudden the price went through the roof unless I bought them mail order.

Also, if you haven't already, take a look at the drug list at Walmart and Target. If you are taking any of these generics you can sometimes save quite a bit by just ignoring the insurance altogether.

http://www.walmart.com/cp/PI-4-Prescriptions/1078664

http://www.target.com/pharmacy/generics-alphabetic

Best of luck and I think your anger toward this is pretty justified. It's very frustrating to be working from behind to figure out what the hell is going on.

[jeff47]

20. No, UHC does this all the time, and not just at re-enrollment.

They'll frequently decide that a medicine is no longer covered, or must be mail-order. At any time during the year. Even when you had no problem refilling the prescription a month before.

And even in NY, where state law says they can not require mail-order.

[one_voice]

22. Well that's interesting...

that's what happened to us. Covered on month and not the next. No notice at all. Just denied.

To me that's very irresponsible. Like I said, they have no idea about my circumstances, even with an emergency over ride (30 days worth)--which they do once you call in--maybe I don't have a way to get back to the pharmacy, for another couple days. Anything is possible.

Then going through getting the mail order set up is an ordeal in and of its self, like I said it took my 2 months to get it set up for my lyrica. They either said they didn't get the paper work from the doctor, or they lost it, or they gave me the wrong number for the doctor to call.

By the time it got done, I was literally in tears on the phone with my doctors office, who I think threatened them, because all of a sudden no problem with the paper work. It did however take them four days to get it faxed from one dept to another. And of course they wanted payment before they mailed it.

I asked why I didn't get the same two months to pay for it as they took to get it to me. Dead silence.

[sharp_stick]

23. Wow

that's an interesting and disturbing point. I didn't know they could actually do that.

[Fuddnik]

44. United Healthcare flat-out sucks.

They pre-approved a colonoscopy for me, and after it was done, they wouldn't pay. And kept coming up with excuses why not.

I used to have them about 20 years ago, and they were pretty good. Now they screw you every chance they get. I'm back with Blue Cross-Shield now, and have never had a problem.

[starroute]

15. I think they're trying to drive local pharmacies out of business

Maybe not intentionally -- though who knows? -- but that will be the net effect of their attempts to maximize their profits.

Our last locally owned independent pharmacy closed this winter when Medicare Part D essentially froze them out. Now we're using Rite-Aid -- but even there, it costs $5 more per prescription that it would if we bought our medicines at the supermarket, which is the only place in town that has the lowest available co-pay. Or we could drive a few miles up the road to Target -- but no pharmacies are included.

No doubt forcing people to buy drugs only by mail will be next.

[pa28]

16. United pays their CEO $50 million a year.

To "earn" that kind of pay you've got to consider every claim a cost needing to be cut or eliminated. I'm glad to hear you are switching because plenty of anecdotal evidence out there points to United being in the business of screwing their policy holders.

[duhneece]

49. United/Optum had our state Behavioral Health Admin contract

Bad news.
Four year (locked in), One Billion Dollar contract to administer Behavioral Health (for substance abuse and mental health) for all of New Mexico.
Horrible service.

[cui bono]

60. That salary is obscene. n/t

[pa28]

67. United has the worst ratio of ceo to employee pay in the country. 1737:1

After being burned in similar ways to the OP I've developed a personal rule. If the CEO makes outrageous money you can bet customers and investors alike are being stripped. Stay away.

[BrotherIvan]

100. That is excellent advice

Could you tell me if there is a good website where to look up the CEO salary? Do all public companies have to report?

Thanks

[FLyellowdog]

17. GEHA does the same thing with Medscripts...why must things be so difficult?nt

[CBHagman]

18. Sharp Stick's post seems to have the most practical information.

I'm afraid I don't have any additional input, except to echo the suggestion about being sure your prescription is continually filled in mail order, and to say that I had rotten experiences with UnitedHealthCare when our company had its coverage with them (We're with Blue Cross Blue Shield now).

[randome]

25. Was this for Walgreen's? Didn't they drop a number of health insurance prescription plans recently?

[hr]
[font color="blue"][center]Stop looking for heroes. BE one.[/center][/font]
[hr]

[chillfactor]

33. Good God I hope not!

I am on Medicare with a side insurance plan that merged with Medicare..I take 6 medications a day and I pay a $5 co-pay for each prescription...the savings has been very significant as many of my prescriptions would cost $200+ a month if I had to pay out-of-pocket...

[MiniMe]

36. It isn't the pharmacy in this case, it is the insurance company formulary

The insurance company decides what they will cover, and how, and what they won't. They pharmacy will give you what the doctor prescribed, but you may have to decide to pay retail price, and try to get reimbursed by insurance later.

[csziggy]

54. Express Scripts dropped Walgreens for a while but has now allowed them

I was getting all my meds through Walgreens - 24 hour drive through window was convenient when my husband was working evenings and nights. I could call in the refills and they'd be ready when he got off work.

When Express Scripts dropped them we switched to Publix and the copays were less. I'd change to Costco, but it's way out of the way and convenience is worth more than what we'd save. Most of time now my husband is not working the hours he was before, so Publix's limited pharmacy hours are not a big inconvenience.

Our insurance some time ago forced us to a mail order place. They got the scripts wrong, then wouldn't refund for the incorrect med. I reported them to the Texas Board of Pharmacies. Several years later, well after our insurance coverage had changed, I got a refund, forced by the Texas Board!

Now, every year Express Script harasses us, trying to get us to use their mail order facility. I complain every time they call and tell them to never call me again, but they that their contract with my husband's employer requires them to "offer" their services. A$$holes.

I will never willingly get my meds through a mail order or internet order place. I want a local pharmacy - I also want all my meds through the same pharmacy, so if I get a prescription that must be filled immediately, I can drive to the same place all the others come through and hopefully the pharmacist (or the pharmacy software) will catch any incompatibilities.

[Behind the Aegis]

26. It won't help much, but all I can say is...

[liberal N proud]

27. I go through this with Nexium

You have to get the doctor to write a letter to the mail order company or whoever is overseeing the approvals that this is the only medication that works for your prognosis.

Make sure your doctor gets it long term in writing and get a copy for yourself if you can.

[Aristus]

28. I don't know how smart I am, but this is kind of my field, so I'll try to help.

Believe me, I sympathize. Seem like half my job is arm-wrestling the insurance companies best two-out-of-three just to get my patients the medication or diagnostic testing they need. (Probably around 1/3 of my homeless patients have insurance; either state insurance, or private insurance held over from when they were employed, or that they earn enough to pay the premiums for.)

Are you allergic to pregabalin, the generic for Lyrica? Or another drug they said they'd cover? And unfortunately, pregabalin is not available on the low-cost formulations offered by companies like Wal-mart, Fred Meyer, or Target.

It's clear these people don;t know anything about medicine; although that doesn't stop them from essentially making medical decisions. Abrupt withdrawal from Lyrica can cause seizures. And if they won't refill your prescription in a timely manner, they are ethically responsible for any adverse effect you may suffer.

Your husband's medication, the generic of which is sitagliptin, is a very effective med for Diabetes. But it's also expensive, and also not on any of the $4 lists.

If you have any other questions, I'll try to answer them. But it seems like your best move at this point is to re-enroll with Blue Cross when the period expires.

[one_voice]

38. I didn't know there was a generic for Lyrica...

no they wanted me to take Neurontin-or the generic version. I CANNOT take that drug.

Your first paragraph is another problem I brought up to them. Do they really think that doctors/their staff/PA's have nothing better to do than to jump through their ridiculous hoops? I've been with my doctor since I was 14, and that's been many, many moons ago. My kids haven't seen anyone but him. He's a great advocate for his patients, his staff is great, but even the best have their limits with the idiocy of the insurance companies.

Like I said, I worked for insurance companies in the past and we did everything we could to make things easy for our insured. We had nurses working with us we didn't make decisions that should be made by a medical professional. They have lay people making medical decisions its asinine and unacceptable.

As for my husbands medicine they did give me a 30 day over ride, but now I get to play the same game with them that I did with the Lyrica. They did say if my doctor approves they'll fill either Onglyva or Tradjenta locally otherwise Januvia has to be mail order.

I'm going to make an appt. to go in and see my doctor.

I don't know how it's legal not to notify me either by email or letter that they're not paying for certain drugs at the local pharmacy.

[Aristus]

41. They usually notify the provider first.

In my experience.

Hang in there...

[haele]

30. You need to talk to your HR rep about that.

Your HR should have an EAP rep to deal with the insurance company, and maybe get you a NP Ombudsman to work with meds and appointments, especially since there is a chronic, life-threatening health issue involved.
We had a similar issue this year when my employer took a different AETNA package to save money; my spouse is permanently disabled and has psych issues and diabetes as well as arthritis; we were suddenly hit all sorts of crap with the mail-order pharmacy that was now a different company (Accredo/Medco) than the regular prescription pharmacy (Express-Scripts) even though everything was being paid through Express-Scripts, so we were always having pre-authorization issues (every month the doctor had to send the letter for one of the cheapest medicines).
And (get this!) after we hit our PPO family deductible of $3K (which we reached in early April), all prescriptions through Express-Scripts were now $5.00 or 10% for patent/name medications every month, but the 3-month mail order prescriptions had a deductible of $9K and we still would be required to pay the 1/3 retail price for the medication - so his three normally mail-order meds would be $1200/$873/$425 for 3 months of meds and required pre-authorization every time we need to refill, but $25/$5/$5 each month if we ran the prescription through Walgreens.
The Aetna NP that my HR requested (per the free wellness plan package) is in contact with my spouse every other week, and has gotten the pre-authorization requirements waived for the Express-Scripts prescriptions, but she wasn't able to do anything about the 3-month mail-order. She advised us to dump the mail order and just walk in; the price difference alone - even paying for the gas every month to pick up his prescriptions - was enough to get us to agree with her advice.

She was also able to get my spouse some realistic alternatives for diet and exercise that he could do in his condition and is helping us get through the process of having Aetna pay for getting him a wheelchair and other non-prescription medical devices to ease some of his issues and help cut down on long-term costs as part of the wellness program.

For-Profit Medical Insurance - they really don't want to make it easy for someone who isn't already healthy to get health care, do they? But they do love our premiums.

Haele

[southernyankeebelle]

31. Ask your insurance company if you can use Express Script. They are pretty good. They

will mail it to your home. Your doctor can send them a script up to 90 days. You can at least try and ask. All they can say is no.

[Ms. Toad]

69. In my experience, they stink. n/t

[southernyankeebelle]

79. Really? I have never had a problem with them. I have been using them over a year now.

[tammywammy]

77. I use Express Script as well, and have never had a problem. n/t

[southernyankeebelle]

78. me neither.

[Nay]

97. I've used Express Scripts/Medco for years now and have nothing but praise for their service.

Online or on the phone, they've been great.

[southernyankeebelle]

99. I haven't heard of Medco. Do they handle everyone? I know Tricare handles retired military families

[Nay]

102. I started out with Medco, but ExpressScripts bought Medco and now they are the same. nt

[southernyankeebelle]

103. Oh I see. I just never heard of them before.

[Ms. Toad]

108. The same, but not.

Medco was competent & cared - ExpressScripts, not so much.

[Nay]

109. This certainly may be true -- it does seem that they have kept all the same Medco processes,

the website, etc., and probably all the people as well. If ExpressScripts was smart enough to let the former Medco continue its operations as before, then Medco subscribers are better off than ES subscribers. I hope ES doesn't start meddling with Medco's success.

[Ms. Toad]

110. They already have.

They already have. The customer service changed dramatically, from my perspective, shortly after Express Scripts took over.

For one thing - on average - the customer service representatives went from being able to solve everything in a single phone call to taking multiple phone calls to solve issues, giving me inaccurate information (which I could verify against my plan information - since I make it a point to know my plan backward and forward) and to telling me - we may never resolve it, and it isn't something you're entitled to (with respect to Web access to prescription management and history for one family member - lingering for 5 months). I did ultimately get the web access resolved - but it took getting Medical Mutual involved and 5+ hours of my time over a two day period one I decided I was just going to keep both companies on the phone until they resolved the matter.

When I got a customer survey phone call from Medical Mutual, I told them I was extremely unhappy with the switch to ExpressScripts - and they said that seems to be a theme with everyone they contacted.

(The prescriptions which are on auto-pilot are rolling along just fine - it is when there are glitches and I need human intervention to resolve them that the contrast between Medco and ExpressScripts is pretty stark.)

[M0rpheus]

32. Talk to your husbands benefits representative, ASAP.

For most plans there is an escalation procedure for cases like this.

Press the benefits person hard, on the fact that these are needed medications that your husband cannot do without. They should be able to get it taken care of in short order, at least on a one-time basis, in order for you to get his medications at the pharmacy. Make sure to note that there was no notification of this change from the insurance company, nor them.

If it's a larger company, don't be afraid to threaten to go far over their heads, to the CEO of the company (Those calls get immediate action, in most cases.). If benefits administration is outsourced, then call the office of the CEO for the benefits company.

I'm the guy who took the calls from the CEO's office of *big huge benefits outsourcing company*, that call can make miracles happen (in 30 mins or less).

[dickthegrouch]

34. I'd write the same letter as your OP

to the consumer unit at your local TV stations and the State's insurance commissioner and the HR dept and the insurance company.

Make the point, as above, that sudden withdrawal from Lyrica can cause seizures.

Tell them all the law needs changing to require minimum 60 days notice of any change in benefits, administration or process for anything to do with medications to both the consumer and the providers (and by 'providers' I mean The doctor, the employer supplying the insurance coverage, the pharmacy and the claims administrator). Scare them into thinking they'll be responsible for even more paperwork and see what happens.

[LiberalEsto]

35. Oh, crap. We now have United Healthcare.

My husband just started a new job, and it looks like we'll be in the same boat as you with this rotten excuse for a health insurance company.

[Butterbean]

37. Oh, God. UHC is a nightmare.

We dealt with them for a couple of years before we'd finally had enough. They are HORRIBLE. The only thing I can suggest is to save your prescriptions (or maybe get two copies, and explain to your physician WHY) so that you have a back up copy when the mail order service craps out again. That way, you can take it to a pharmacy and still get it filled but pay out of pocket if you have to for one or two doses to get you through. I've done that before.

OR go to your local health department. Also, SAMPLES! Next doctor's appointment, make sure to ask for piles of samples and stock up. Keep them on hand for emergencies just such as this.

UHC is a criminal operation, I agree. They are just horrible.

[TexasTowelie]

39. I'm on the Pfizer Connection-to-Care program to receive free Lyrica to treat neuropathy.

I'm uninsured and had my previous doctor work with me to get into the program. It was a nightmare that required multiple phone calls and fighting with the CSRs to get the prescription filled. Pfizer continuously lost paperwork and sent me letters indicating that they needed more documentation even though I already provided the information multiple times. I ended up going without medication for nearly a month and was in such severe pain that I could barely walk and I would wake up during the night with nerve pains.

I recently switched over to a local medical assistance program for insulin and Lyrica since I'm indigent. Getting the insulin prescriptions filled was relatively easy, but I already received a letter from the Connection-to-Care program from Pfizer with more BS indicating that the nurse practitioner needed to provide more documentation. The NP faxed the forms to them yesterday so it will be interesting to see how things get resolved this time. I have enough Lyrica to get through around the 20th of June, but I know from personal experience to expect headaches and delays when dealing with Pfizer.

[HiPointDem]

40. it costs money to notify you, money that would be better spent by rich people. you've made

the mistake of thinking the health care system exists to provide health care.

[snappyturtle]

42. This is a very simplistic answer but I had trouble once and had to switch to a different

pharmacy. Then I got what I wanted, when I wanted it.

[TygrBright]

51. UHC = Satan's jockstrap. They are the Monsanto of "health." n/t

[lillypaddle]

53. I use Optumrx, too (United Health Care)

My first prescription order experience was much like yours - had to finally try to get it filled at CVS, then went through the denial & then voiding of the original request. However, once that was straightened out, I have continued to use them as a mail order pharmacy and have finally been pleased with their service. It's been 7 months now and I've had no problems whatsoever.

I urge you to continue with the mail order service and see if things aren't straightened out.

[williesgirl]

64. l'd start by creaming them with the truth on FB, LI, TWITTER

And make sure you say you're hoping that others will learn from your mistake and not enroll with UHC now or in the Fall. I think they are also affiliated with AARP. Check to make sure of that first, but is yes, make sure to nail AARP as well.

[LiberalAndProud]

66. Wow.

It looks like a little bad publicity goes a long way. You got a uhc rep to offer to help.

Again I say, Wow!

[Turbineguy]

71. They were hoping you'd die.

You don't seem to be playing along.

[Ms. Toad]

73. First - I'd follow up with the person from UHC who posted here.

One of the things I would ask for is

(1) A copy of the prescription drug coverage policy which explains (generally) what you are entitled to
(2) A copy (or link) to the current formulary
(3) A clear explanation of exceptions to the formulary (step therapies on the formulary are easy to get approval for; drugs off formulary are harder - but generally not impossible; there may be other categories as well)
(4) A copy (or link) to the policy and forms required for pre-approval of medication or step therapy

My first step is to get know my policy better than any customer service rep who may answer the phone. That way when someone gives you bad information you can call it to their attention immediately, rather than researching it later. If they can't resolve it, you can immediately ask to speak with a supervisor. They often (not always) know more than the average customer service rep. Take names and notes. Document everything. If they can't resolve it immediately, get a specific commitment as to what the next step will be, who will take it, when it should be done, and how you will know it is done.

If that doesn't resolve matters, and the prescription coverage is included in your insurance but handled by a different corporation, get on the phone with your insurance company. Your contract is with them. They won't like getting calls about drugs, and you may have to ask to speak with a supervisor there, but ultimately if the entity they choose to farm you out to for drugs isn't behaving, they need to make it right. Again - document.

As noted by others, try the rep through your company (or the insurance agent if no HR rep). I used mine for connections - but the reality is that I knew more about my policy and the law than she did. But there are times you may need their connections (and you may be lucky and they may be really good).

If all else fails, appeal. I hate appeals. My personal philosophy is to make them follow their own procedures without appealing and save the appeal if I am technically out of compliance with the policy (like, for example, when Kaiser imposed both a period and a # of visits on a specialist who was previously subject to unlimited visits in that same time period and neither my doctor or I noticed we were within the period, but beyond the # of visits). They will tell you to appeal everything. Even when it is their screw-up. I don't - so I don't know whether that works. I do know that I have never lost a battle I chose to fight (and in 2 decades can only remember two battles I decided weren't worth it).

Good luck. It is, at least, satisfying when you get to the point where you routinely win.

[Hekate]

105. ^^^^THIS ^^^^^

I hope the OP prints out your post and uses it for a template for this and all future actions. to you.

[Ms. Toad]

107. Thanks.

I've just been there, done that, with far too many insurance companies.

[2naSalit]

75. Good Grief!!

After reading all the comments and the OP, I am glad I haven't had any insurance for many years, and very thankful that I have been healthy so far.

I have friends, in their 50's and 60's who have BC/BS ins. and several needed back surgery recently. only the ones who were able to get several surgeons to argue on their behalf were able t get the much needed surgery. And that has had me thinking about insurance issues for weeks now. And on top of these cases, I just started a new job recently where I will actually have the rare opportunity (?) to have healthcare insurance that I would pay half of the premium for. My boss just called while I was reading this to inform me that it would be an amount equivalent to my rent on a monthly basis... my rent is half of my income and I live in some of the least costly housing available!! I asked if I HAD to have the insurance, mentioning how it was like doubling my rent, and the answer was "no".

I think I'll listen to what the rep has to say in our meeting next week but I also think that I will decline. I rarely get sick, don't have any need for regular medications, and considering what a rip off the insurance cabal is in the first place, I think I'm better off without throwing my hard earned pittance into their pocket. If I do get some disease, I'll live with it until it kills me, something's going to eventually anyway... but that's my personal choice. Maybe Obamacare will be an option I can find acceptable and affordable, maybe. I don't like the idea of being cast into the medical industrial complex if it isn't going to be of any benefit to me as a nonuser.

I hope that you can get your issues resolved with your need for medications, it's not looking too good for we baby boomers these days. Seems that the real death panels are the insurance companies, and they seem to function with impunity.

[Jane Austin]

76. United (Senior's Choice) is doing that to me, too.

They've disallowed my thyroid meds (!) and two other important meds I take.

The thyroid meds are super cheap. What's their problem?

[leftyladyfrommo]

101. When I had United they were always pushing me to use mail order

thru Medco - which is probably a subsidiary.

I don't like having my drugs mailed. Takes longer and who knows what outside temps the drugs have been exposed to. Too much or cold can really affect drugs.

[Jane Austin]

80. I think the thing that is so wrong about these problems

Is that the ill are often too tired or too old to carry out these battles.

If you are dealing with more than a couple of problems - health, housing, food - you can be easily overwhelmed and not do anything.

It is very unfair to put sick people or elderly people through this mess.

It is also unfair to put hometown businesses out of business.

[dkf]

84. If you are that sensitive to any particular drug you should check before you go to the pharmacy.

I don't think you can assume that everything will stay as is. In fact I'm pretty sure they have some language that they can change whatever drug they prefer for your condition at any time. They usually have a way to override this but you probably need documentation.

As there is more of a move to cut costs we will see more of this not less.

Part of the value of the VA system is that they have the records to see which drugs work well at the best price. This type of research will start driving more decisions as records are kept track of electronically.

Since Obamacare only recently started all this record keeping we are only at the beginning of picking the best drug for the cost.

People who can't use the generics or the less costly drugs will be affected no doubt.

[Ruby the Liberal]

88. I was just switched to United Healthcare in January

I hate these people with the heat of 1,000 suns.

Never and I mean NEVER in my life have I had more issues with no-brainer issues as I have with this crew.

Lets check the google...

AND as per expected. 8th highest paid CEO in the country would be one Stephen J Hemsley at a cool $48.83 million for 2012. http://www.forbes.com/lists/2012/12/ceo-compensation-12_land.html

Surprise, surprise.

[one_voice]

90. This is only the latest issues with them...

I cannot wait to get away from them. I had Blue Cross before them and I will go back. They weren't perfect but they were a heck of a lot better than this.

Most of the people I've had contact with have been completely incompetent.

[Glimmer of Hope]

89. I went through similar aggravations with my insurance a few years ago when I had a lot medical issues

I learned that they intentionally deny claims, lose submitted claims and deny prescription coverage. Every third check that was sent to me was "lost in the mail'. They do this because a certain percentage of people do not follow up or give up in frustration. They are being assholes on purpose.

[TheKentuckian]

92. I checked the formulary and your Lyrica is non-preferred and yes, has a specialty pharmacy only

so I think you are stuck and sadly, have to count yourself fortunate that they didn't put a step therapy requirement on your medication like the rest of the tier.

My suggestion is to go ahead and set up the mail order. Many policies have a one time emergency fill at the local pharmacy if you need it right away but if prior authorization is in place then it is possible that Optum can get your medications overnighted.

I just don't see how it is worth the effort trying to appeal or to get an exception because it will probably go nowhere unless your doctor is bulldog that knows the criteria better than they do for this but sure understand your frustrations. I also think they have enough legal language to make it near impossible to have an insurance commission do anything to rein them any.

Health care is just not a rational market and it is pretty much crazy to treat it as such so folks end up like you, a captured consumer that is fully dictated to by the seller.

[one_voice]

93. I don't mind the mail order...

What I objected to was that they were filling it at the local pharmacy and denied it without any notice. I had to get prior authorization even with the mail order because they wanted me to take a generic version of a medication that I cannot take.

So my doctors office had to call repeatedly because they (OptumRx and UHC) couldn't get their shit together. So I did have to have my doctor submit something to verify that I had to take they Lyrica and was unable to take the other drug.

Mind you this was after I was told 4 different things from 4 different people as to what I needed to do to be able to get my Rx filled. It was ridiculous. When I asked to speak to a supervisor, they put me on hold for 25 mins at which point my call was disconnected.

They had been paying for the Lyrica since Jan, I don't have an issue with mail order, I had an issue with the way they handled the discontinuation with using the local pharmacy. One other thing, the med they wanted me to take wouldn't have been filled locally either.

Then they did the exact same thing with my husband's medication.

It seems their policy is to just deny coverage when they want you to either switch medication and or go to mail order. It's as if they're to friggin' lazy to send out a letter stating this.

This will be your last re-fill for this medication. Please contact us at (phone number) to set up mail order.

Like that's so freakin' hard. I PAY A LOT of money for coverage, I don't get anything for free. I wish they'd quit acting like they're giving me something that I should be grateful for. I am the customer. Somewhere along the way that has gotten lost.---rhetorical, repeating basically what you said. it's so frustrating.

[vanlassie]

98. Many policies have a mandatory mail order

requirement after a certain number of local fills. Sounds like that's your plan. It often comes as a shock.

[gopiscrap]

104. I hate fucking insurance companies

we definitely need to be a single payer nation

[MountainLaurel]

111. Something like that happened to us recently

Our health insurance plan will not pay for more than 3 months of a drug unless you receive it from a mail order place (Medco). The problem came when we tried to get our doctors to send a new prescription to the mail order company: The physician's offices wouldn't write new prescriptions elsewhere because according to their records we still had refills available: mind you, these employees work for the same hospital I do. Apparently they were just that unaware of their own employers' policies. Because we couldn't afford to pay for the prescriptions out of pocket, we did without. It took 3 weeks to talk to human beings to get the prescription issue straightened out, and then another 2 to get the drugs from Medco. In total, Mr. Laurel was without his anti-seizure meds for a month, and I was without an antidepressant for 2 weeks.

Good times were had by all.