Colin is on two different medicines to keep his seizures controlled. We are beyond thankful to have found the combination for him and hopeful that he will be off them in the next year. We pay a lot of money monthly for these medicines though and are being screwed.
One of Colin's necessary medications is a compounded medicine. Technically it costs $5 for this medicine but because Colin is a child he needs it in liquid form and insurance says this is UNNECESSARY so we pay for 90% of the medication OOP every month. Mind you, this medicine is only made in special compounding pharmacies and there is only one in our town. Now insurance won't cover that ONE pharmacy. We HAVE TO go to walgreens and Walgreens only and none of ours can make this medicine.
So, our options are: pay 100% OOP to stay at the local pharmacy or drive no less than one hour roundtrip to go to a compounding pharmacy that can make this medicine. They refuse to give an exception and have told us tough luck. My H went to his HR benefits coordinator today and she told him tough luck and even suggested Colin be put on a different medicine (uhh it doesn't work that way with this sort of medicine. You can't just switch or stop and when you find something that works you don't change it!)
So, while we pay hundreds monthly in insurance coverage we cannot even easily get my kids medicine that keeps him from having seizures. I am so mad and we were not even given warning that we wouldn't be able to get his medicines anywhere but walgreens. Insurance also refuses to call my local walgreens to see for themselves that they can't produce my kids medicine.
We looked into mail order and they can't with this one.
Beth, I think you work for UHC right? Our prescriptions are through Optum (spelling?)
My H's company is based out of the same place as Walgreens so we think they have a special contract now. We have always gotten special walgreens discounts so it makes sense
We looked into mail order and they can't with this one.
Beth, I think you work for UHC right? Our prescriptions are through Optum (spelling?)
My H's company is based out of the same place as Walgreens so we think they have a special contract now. We have always gotten special walgreens discounts so it makes sense
Ask his doctor to call optum rx and get it authorized to be done elsewhere. It is called a gap exception. His doctor should be able to write a letter of medical necessity to prove that it has to be done this way. If it is authorized to be filled elsewhere then we have to pay it. I review these daily and it should not be a problem at all to get it fixed, I don't know why they are giving you such a hard time about it. I would call and ask for a supervisor, I can get some names for you tomorrow if you need me to.
Post by LiveLoveLearn on Apr 9, 2014 18:26:55 GMT -5
That is so frustrating! I will agree with what Beth said I know I have heard of exceptions that can be done if the doctor calls the insurance company but couldn't think of what it was called.
We looked into mail order and they can't with this one.
Beth, I think you work for UHC right? Our prescriptions are through Optum (spelling?)
My H's company is based out of the same place as Walgreens so we think they have a special contract now. We have always gotten special walgreens discounts so it makes sense
Ask his doctor to call optum rx and get it authorized to be done elsewhere. It is called a gap exception. His doctor should be able to write a letter of medical necessity to prove that it has to be done this way. If it is authorized to be filled elsewhere then we have to pay it. I review these daily and it should not be a problem at all to get it fixed, I don't know why they are giving you such a hard time about it. I would call and ask for a supervisor, I can get some names for you tomorrow if you need me to.
I love you. Thank you.
I talked to Terrence in Optum (something about him being in escalated) and he was ruuuuude.
Would the fact that my H's employer has a special contract with Walgreens affect approval? The pharmacy we go to says they have a contract with Optum and plenty of patients with it and we are the first to have any issues.
I spent at least three hours yesterday calling various walgreens and talking to UHC and they basically just said "sorry." I even talked to a nice woman at UHC who tried to see if I paid 100% OOP could I try and get paid back and Terrence told her no.
Ask his doctor to call optum rx and get it authorized to be done elsewhere. It is called a gap exception. His doctor should be able to write a letter of medical necessity to prove that it has to be done this way. If it is authorized to be filled elsewhere then we have to pay it. I review these daily and it should not be a problem at all to get it fixed, I don't know why they are giving you such a hard time about it. I would call and ask for a supervisor, I can get some names for you tomorrow if you need me to.
I love you. Thank you.
I talked to Terrence in Optum (something about him being in escalated) and he was ruuuuude.
Would the fact that my H's employer has a special contract with Walgreens affect approval? The pharmacy we go to says they have a contract with Optum and plenty of patients with it and we are the first to have any issues.
I spent at least three hours yesterday calling various walgreens and talking to UHC and they basically just said "sorry." I even talked to a nice woman at UHC who tried to see if I paid 100% OOP could I try and get paid back and Terrence told her no.
I might PM you in a bit.
Any contract or affiliation with walgreens shouldn't matter. With a gap exception if there is not a provider or facility within 30 miles that is in network then we can do an exception if your doctor can prove that it has to be done this way. It will be reviewed by one of our medical directors (a Doctor) and then they should approve it. and even if they deny it then your doctor can do a peer to peer review, which is basically a phone call between your doctor and the medical director whre your doctor can argue his case.
I really hope this can be fixed for you soon. If you have anymore questions you can pm me
Post by livinreality on Apr 9, 2014 18:43:08 GMT -5
I have nothing to say other than I can commiserate. R was on compounded prevacid for 18 months, we only have one compounding pharmacy and it was not covered by the insurance, it was $50 every two weeks.
Ugh this is awful. It is so difficult to get the proper cocktail and those drugs absolutely cannot be abruptly stopped as you said. I was hoping the doctor could advocate regarding medical necessity so I hope it works as beth422 advised. Hugs honey!
I talked to Terrence in Optum (something about him being in escalated) and he was ruuuuude.
Would the fact that my H's employer has a special contract with Walgreens affect approval? The pharmacy we go to says they have a contract with Optum and plenty of patients with it and we are the first to have any issues.
I spent at least three hours yesterday calling various walgreens and talking to UHC and they basically just said "sorry." I even talked to a nice woman at UHC who tried to see if I paid 100% OOP could I try and get paid back and Terrence told her no.
I might PM you in a bit.
Any contract or affiliation with walgreens shouldn't matter. With a gap exception if there is not a provider or facility within 30 miles that is in network then we can do an exception if your doctor can prove that it has to be done this way. It will be reviewed by one of our medical directors (a Doctor) and then they should approve it. and even if they deny it then your doctor can do a peer to peer review, which is basically a phone call between your doctor and the medical director whre your doctor can argue his case.
I really hope this can be fixed for you soon. If you have anymore questions you can pm me
Lol of course we just map quested it and it's like 25 miles each way. Is the 30 miles each way or round trip?
I have nothing to say other than I can commiserate. R was on compounded prevacid for 18 months, we only have one compounding pharmacy and it was not covered by the insurance, it was $50 every two weeks.
We are dealing with the previcid issue too now. They want to charge us $90 now for compound when it's a $5 prescription covered in pill form.
I just haven't even touched that issue yet because we currently have a half bottle left. Give me a week and I'll be crying lol
Any contract or affiliation with walgreens shouldn't matter. With a gap exception if there is not a provider or facility within 30 miles that is in network then we can do an exception if your doctor can prove that it has to be done this way. It will be reviewed by one of our medical directors (a Doctor) and then they should approve it. and even if they deny it then your doctor can do a peer to peer review, which is basically a phone call between your doctor and the medical director whre your doctor can argue his case.
I really hope this can be fixed for you soon. If you have anymore questions you can pm me
Lol of course we just map quested it and it's like 25 miles each way. Is the 30 miles each way or round trip?
aww man! it's 30 miles one way. I would still have your doctor try, it wouldn't be a gap exception but they can still try to get it approved since this is the only way it works. worse case scenario you are back to where you are now. It wouldn't hurt to have the doctor try.
Lol of course we just map quested it and it's like 25 miles each way. Is the 30 miles each way or round trip?
aww man! it's 30 miles one way.
Omg that sucks. Because driving round trip 50 miles with a toddler and 3 month old is something I want to do when there is a pharmacy two miles down the road that even delivers to us!
FWIW, I know it's not the company you work for doing this so I hope you don't think I'm bashing them. This is on my H's employer.
Omg that sucks. Because driving round trip 50 miles with a toddler and 3 month old is something I want to do when there is a pharmacy two miles down the road that even delivers to us!
FWIW, I know it's not the company you work for doing this so I hope you don't think I'm bashing them. This is on my H's employer.
Oh I know I'm not taking any offense. The system sucks and unless you know the right loopholes then it is a lot harder.
Ugh that's so frustrating. We had to pay a lot for Lily's Axid OOP as well. I just found out this year there is a process to submit claims that weren't paid. I went back and got receipts for all her prescriptions and got 80% back, I'm appealing a few that weren't covered. Does your insurance have anything like this? I hope someone advocates for you and helps you out.
I agree with Beth, get your Dr's office to work on it. What med is it? Some seizure meds can be crushed, and others can't (which you already know) so maybe what he is on can be crushed and taken with some applesauce?
I am so sorry you're dealing with this. I am the one who gets all of the medication prior authorizations and formulary exceptions for my office, I know just how frustratingly ridiculous the insurance companies can be. I definitely agree that you should talk to his doctor about getting it authorized for him. And saying that the liquid is unnecessary is enraging. Show me a two year old who can swallow one of those. Gah. I hope it gets figured out soon and you stop getting screwed. Lots of hugs.