About a month ago, I ranted about how difficult it was for me to fill the AdderallXR prescription for Sticks. I was ultimately able to do it, but only after I dug into my pocket and came up with $356 for 90 days. That was my cost because I was unable to get a prior authorization from Blue Cross so that I could at least get the discounted price.
Before I go on, here’s the overview of the steps I have taken to try to minimize my out of pocket costs:
- I am paying for the most expensive flavor of health insurance through my employer. That means that I’m supposed to have the best copays, etc. and the structure is a PPO. Whenever possible, I stay in-network to minimize my copayments and the expense to the insurer.
- I have about $320/month deducted from my paycheck and set aside into a cafeteria plan for medical reimbursement. I increased this deduction in 2004 with the understanding that I was unlikely to get any approvals from AdvancePCS for ADHD medications and so factored in the full cost of the medication to my deferral.
- In 2005, my employer introduced a debit-card approach to the medical reimbursement program. This was a true benefit to me, because it meant I didn’t have the cash flow issues that have plagued me whenever filling prescriptions.
- I ask for a 90-day supply to be written. This is because AdderallXR is a controlled substance and cannot be filled by mail. Given that I’m assuming the cost, I want to do it with the best deal, which is still a ‘bulk order’.
For a 90-day supply of 30mg Adderall XR, the cost was $356. For a 30-day supply of 20mg AdderallXR, the cost was $140. Multiply that 30-day supply by 3 and it’s $420 for the same 90 days for a lower dosage. A HUGE difference!
The debit card was a godsend until March. For some reason, in March it started declining at the pharmacy. This was a problem. I went to the administrator’s website and looked up my account. All of the declined transactions were annotated with the term “PBM Mismatch”.
What did that mean? Good question, and one that I still have no good answer to. Evidently, that term is a catch-all for a transaction that didn’t jive in the database with no good reason. It happened to us with Zyrtec-D in March and then again when I went to fill the AdderallXR prescription in May. In between, I spent a TON of time on the phone with these folks. The only answer I could get that made ANY SENSE was that I had not gone through the prior authorization process yet again for another turndown and so it was rejected by the PBM (pharmacy benefit manager aka AdvancePCS, dammit!) !!
Keep in mind here that we are no longer talking about the insurance company’s money. We’re talking about MINE. And if I don’t use it, I LOSE IT. And they have kept me from using it. What the HELL KIND OF BENEFIT IS THAT?
And then we descend into customer service (and I use the term loosely) hell. I am not in a financial position to have $300/month deducted for benefits and still have to come up with $350 bucks to fill a prescription, even when it’s every 90 days. It’s hell on the cashflow. So I call up the FlexPlan administrator and ask them to please research this problem and figure out why it’s bouncing back whenever I use the card at the pharmacy. It works beautifully at the optometrist, dentist, doctor, and other providers. Just the pharmacy. Just the medications declined by my wonderful PBM, the ripoff artists known as AdvancePCS aka Caremark aka BlueCrossBlueShield. Why IS that?
After literally hours on the phone with these folks, the best answer they can give is that I have to have that PBM denial in place to invoke the debit card. Fair enough.
I went to the doctor on August 29th and asked him to change my medication to AdderallXR. I had decided that I was entitled to a medication that actually WORKED, just like Sticks. So I dutifully paid my $25 co-payment for the 4-minute discussion about changing meds and trotted to the pharmacy. Dropped off the script on August 30th with the admonition that they would have to get the prior authorization via the doc’s office before filling the script. Chose to go without meds until this was filled rather than pay for more ineffective stuff.
September 16th – I receive a call from the pharmacy that my prescription is ready for pickup. I go to pick it up, and am rung up for a cost of $140. I know that’s not right, because that would translate to $420 for a 90-day supply, which is WAY MORE than I paid just 2 weeks earlier for Sticks’ meds. So I tell them, hey, do you have the prior auth?
And they say…no, you have no insurance. WTF????
After going around for a bit, we discover that the HIPAA changes caused a problem with the ID and they find the right plan and they find the right ID and inform me that they will fax the request for PA to the doctor right away. Sigh. Okay, what can I do but wait? So I do.
I get a call from the insurance gal in the doc’s office on Monday letting me know that she’s concerned that I get the right dosage approved. She wants me to come back and see the doctor to see if we have the right dosage. I patiently explain that we don’t have the right dosage because they HAVEN’T FILLED THE F-ING SCRIPT THAT HE WROTE FOR THE STARTING DOSAGE. HELLO???!!!!! She finally gets it. And says she’ll fax in a letter asap. Thankyouverymuch, I growl, hanging up and grousing. Not the right day to quit smoking, for sure.
Tuesday I get another call from the gal in the doc’s office. I take it with fear and trepidation, but it’s good news. She says she’s not sure what’s going on, but they approved it on the first request without any trouble! Yippee, I’m on my way. So I ask — do you let the pharmacy know or do I? She says…”hmmm, why don’t you do it?” LOL…service is just sucky all over the place these days, but okay, I do it.
I call the pharmacy and tell them to fill it, that it’s approved. Then I make the next mistake and ask how much it will be, thinking that since it’s on their list of preferred medications (non-formulary, of course), it’ll be in the $35 range.
I am told that my copayment will be $96.00. WTF AGAIN!!!??? Let’s see…$96.00 is about 69% of $140. So under the current cost-containment policies, I am responsible for 70% and my beloved PBM (AdvancePCS, the EVIL ONE) is responsible for 30%. And…$96.00 is based on the DISCOUNTED RATE.
I think something stinks. I tell them I will pick it up today, intending to do a bit of research today to see if that’s really correct. Only, my day blows out right at the beginning and goes to hell in a handbasket early. No way do I have time for homework.
Deciding that I have been off meds for 21 days and my life is reflecting the corresponding disarray, I decide that I will use the DEBIT CARD to pay the $96 and fight with the folks at the PBM later. I wait in line along with half of the city at 6:30 pm, watch the pharmacy assistant get dumped on by three or four people in front of me for telling them they owe WAY MORE than they thought they did (or worse, that they are not covered at all).
Get up there, she gets the med and I ask her to just double-check on the cost. She takes that request personally, as if I have somehow accused her of ripping me off, but grudgingly does it for me while shooting dirty looks from over the register.
She returns to the register, informs me that it is what it is and I should take it up with the insurance company (DUH…..I hate when they state stupid, obvious things like that). I hand over the debit card, run it through and am……..
DECLINED. DECLINED, DECLINED. F-NG DAMN. This has now gone from an irritant to a full-blown tantrum-trigger. DECLINED WITH ANOTHER “PBM MISMATCH”.
So I ask her to please, pretty please run through the transaction with my social security number instead of my member number. After being a complete asshole about it, she does it. This is after I have shouted at her and her little pissy manager that I’m not a complete idiot, I’m a benefits administrator and have half a brain and stop treating me like I’m stupid or invisible. Bad form I know, but I’m just at the end of my patience.
She does run it and it DECLINES. AGAIN.
Because I am so angry and because I am so frustrated and because I know that I will not put a coherent thought together to deal with it and follow through with this, I fill the damn thing with my business credit card, which really is earmarked to cover the office rent until the cash flow revives as I meet my current pending deadlines.
And I resolve that enough is enough. If I have such difficulty with my background and professional knowledge, average Joe on the street has no clue. There is no way to navigate this system as long as they have the controls, the strings, the horizontal and the vertical and are without ANY accountability. It’s time to be vocal and active. And so I will be. It is my hope that by writing this, others might read it and brainstorm strategies for:
- getting grass roots support for holding these companies accountable. They are the PRIMARY providers of Medicare benefits and Rx cards for God’s sake. These elderly folks are really at risk for ripoffs because of their half-baked business practices
- defeating the current California proposal to create a political regulatory body (read– appointees!!!!!) to handle health insurance issues in the state
- to force fair claims and benefit administration with regard to cafeteria plans. That means that the PBM cannot be part of the claims/benefit approval process. It is self-serving and unnecessary. Cafeteria plans are subject to ERISA and I plan to make a stink about the constant denials without foundation as defined by the plan.
And I will write about each and every instance I can find of misconduct, people suffering as a result of their so-called cost containment policies. I will not only write here, but I will send email after email to our HR and benefits departments letting them know that they are not getting their money’s worth. It’s time to stop the used-car salesmen of the insurance industry and get our money’s (and our employers’ money!) worth from them.
This is just beginning.
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