Wednesday, February 5, 2014

The Bumpy Ride Continues

On January 24, I posted about the fun times I was having with my new medical insurer regarding medication coverage.  The good times continue, and I continue to learn....

First the good news!  After my opthalmologist re-sent the prior authorization application for Restasis
to my insurer, we were surprised to receive the OK the next day, a Saturday.  I learned of this from my pharmacy who sent me an e-mail informing me my Restasis refill was ready to pick up and there was a $0 charge.  Hmmmm.....  At first I didn't believe it, but when I went to the pharmacy, I learned that it was indeed true.  Well.  I've learned two things from this: the insurer will approve or disapprove as it wishes, and the insurer won't call me to let me know what their decision is.  My last medical insurer always called me, my doctor, and the pharmacy.  It took about a week for my eyes to return to a healthy status once I was back to the normal Restasis dosage.

I thought I'd covered all the bases after my experience with the Restasis.  I had called to ask about my other medications to make sure the questions I had were answered.  One, B12 injections, had been a question mark.  First I was told I'd need a prior authorization for it because I did the injections myself which saves money -- I don't need to trek to my doctor's every 3 weeks for the injection.  I've done these injections myself for the past nine years.  I called my doctor and let them know I needed a prior authorization.  A day or two later, they called me to say my insurer had told them that the B12 did NOT need a prior authorization.  It would be covered without it.  Huh?!  OK.

This past Monday, I called in two refills: one for a medication that was on my insurer's formulary and the B12.  Yesterday, I was dealing with a flare of chronic illness and wasn't well.  I didn't check e-mail until late afternoon.  Walgreens had sent me an e-mail informing me my refills were ready to pick up and both cost the full retail amount.  Huh?!  What is going on with this medical insurer?

I called my insurer, requesting the reason these two medications weren't covered, apparently.  One was on their formulary, the other I'd been assured would be covered.  During this first call, we went through different possibilities as the customer rep waited for another department to call her.  The rep thought it might be a problem with the pharmacy's running the refills through insurance.  We decided that I'd call Walgreens and ask what they'd been doing.

Walgreens resolved one issue on the phone with me -- the generic medication on my insurer's formulary had been written for more than a 30-day supply.  When they reduced the refill amount to a 30-day supply, it went through the insurance claim process fine and was covered.  But the B12 was a mystery.  Walgreens had received only a "drug not covered" message from Argus, the processing company.

So, I returned to my insurer.  I called them again to nail down what the issue was with the B12.  The "department that handles claim rejections" still wasn't answering their phones, so the customer rep said she'd call me when she finally heard from them.  About an hour later, she called.  The rejection reason was "prior authorization only for one day."  What?!  So the claim had been rejected.  Now, my insurer had extended the authorization period.  How long?  The rep had to check, but she returned with the news that it was for one year.  OK.  To be clear, I asked her if this "authorization" was a prior authorization.  Yes.  So, the B12 had needed a prior authorization after all.  Good grief.  At least my B12 is covered, as it should be.

I have now been through one cycle of refills of the medication I take regularly.  Other medications for psoriasis last considerably longer and I refill them about once a year (saving a considerable amount).  I am the type of patient that looks for ways to save money for myself and for my insurer.  The issues I've had with my new insurer have concerned primarily communication problems.  My insurer could improve its communication with its customers regarding its drug coverage policies, its formulary, and follow-through with its customers.  I've learned that being persistent and patient will pay off.  I've also learned that I'm in a much different insurance world now and I must be even more vigilant about costs and coverage.  But I've also learned that my new insurer can grant prior authorizations without an application which I find extremely interesting....   

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