Topic: Huge cutbacks in what Medco, now Express Scripts, will cover---feedback?
Rumigirl
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Member # 15091
posted
Medco, which was bad enough, has now been taken over by Express Scripts, which appears to be even worse.
Over the years the coverage has gotten atrocious, and the bureaucracy is crazy-making! My co-pays and deductibles have tripled, but they are covering only 1/3 of many rx's, if they cover them at all! Of course, my premiums and other payments have doubled and tripled.
Does anyone have any suggestions?
They have been either not covering specific meds at all, or they cover about 1/3 of the rx. I have my dr's offices put in for a Quantity Exception to get the full quantity, but after weeks of many hours per day on the phone (me, my dr's office, and the pharmacist), I still get no where at all, not approved.
I get a robot call saying that the Quantity Exception was approved, I go to the pharmacy, and it isn't approved at all. More weeks and hours, and in the end . . nothing.
Yes, I can appeal in writing, but this is with one rx after another. And an appeal takes over a month, with no guarantees.
I called the office of the President, and although a woman was very nice, in the end, she couldn't help me get approval. I'm thinking I should complain to the state AG's office. But who has time for all this??!!
In the meantime, I don't have my rx's. And the crazy thing is, this is often for inexpensive generics, not new, expensive drugs!!
I don't know what more I can do, other the the state AG's office. But private policies are probably allowed to do whatever they please (unless it goes against the new healthcare law).
Posts: 3771 | From around | Registered: Mar 2008
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I am so disappointed that Medco and Express Scripts now joined forces. I had medco and now am with Express Scripts. I have had so much trouble , too. I pay cash for half of meds. I don't know what to tell you. I have wondered myself.
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Haley
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I have heard that they are like big brother for the insurance companies. They are making sure that the insurance companies don't lose money. I decided to pay more money through regular pharmacies when I found this out. Just my opinion.
Posts: 2232 | From USA | Registered: Aug 2009
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posted
Very scary. My insurance plan just switched from Caremark to Express Scripts.
UGH
You say there are problems with ALL meds?
-------------------- --Lymetutu-- Opinions, not medical advice! Posts: 96222 | From Texas | Registered: Feb 2001
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lpkayak
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i thought express scripts waa pretty good and has just gotten better...but im pretty messed up...maybe its one more wa y im getting screwed over
-------------------- Lyme? Its complicated. Educate yourself. Posts: 13712 | From new england | Registered: Feb 2004
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CherylSue
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My new insurance uses Medco/Express Scripts. I haven't used them yet, as I'm still using my previous supply from my former insurance.
Rumigirl, is the problem using the mailed prescriptions? What about the ones you just take the RX to the pharmacy of your choice, and they fill it?
Just wondering. Thanks.
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poppy
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Sounds like rumigirl has trouble at the pharmacy. Sometimes you can get meds at a pharmacy that you can't get thru mail order, but if they are shutting this down too.....
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-------------------- --Lymetutu-- Opinions, not medical advice! Posts: 96222 | From Texas | Registered: Feb 2001
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Catgirl
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Lyme has opened my eyes to our healthcare system. My husband and I have had to pay out of pocket for the majority of my lyme treatment.
As far as insurance coverage goes, lyme treatment is actually a very good benchmark for identifying what's currently wrong with our whole healthcare system. My husband and I have had to pay more for healthcare every single year.
We either have to pay more out of pocket, or pay higher taxes for a healthcare system. It's that simple. So if we don't want to pay for a healthcare system, we may as well get used to paying more money for anything related to healthcare. That is if we can afford to.
The way it is right now, and if we keep going like this, the people who have the money to pay for lyme or any treatment can and will, and the ones that can't are simply screwed. It's been happening in slow motion for some time now anyway (paying out of pocket, not to mention actually getting insurance coverage).
You can only squeeze a lemon for so long. I guarantee you, the insurance companies will prevail. The only way to change this train's path is by the power of your pen. Vote for something better, because this, right here and now, just sucks. We really need some type of medicare for all.
-------------------- --Keep an open mind about everything. Also, remember to visit ACTIVISM (we can change things together). Posts: 5418 | From earth | Registered: Mar 2011
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posted
The insurance companies WROTE the plan. YES, they will survive.
-------------------- --Lymetutu-- Opinions, not medical advice! Posts: 96222 | From Texas | Registered: Feb 2001
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poppy
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Unfortunately catgirl, unless you are personally affected, you don't care about getting a better healthcare system. And even some who are affected don't see it.
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Rumigirl
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I didn't respond earlier, because I just spent a whole lot more hours trying to get an rx approved, which I've been trying to get approved for a week (to no avail).
The problems I am having is getting them filled for more than a few doses, regardless of whether it is at the local pharmacy or the mail order; it's all the same.
To give you an example: The current rx I'm having trouble with is the generic injectable Imitrex (migraine med). I used to be able to get a Quantity Exception for 12 doses per month with a request from my dr. Now they will only give either 2 or 4 doses per month (I keep getting a different answer). And I'm having horrific daily migraines. No way will that be sufficient.
I've been working on getting a Quantity Exception for a week. I got a robot call saying that it was approved. But when I went to get it filled, it was for the same amount as before. So I've spent the last two days trying again---so far no luck. And I've been out of the med for a week.
Plus, I just found out today that the form I get, the vials, aren't covered at all!!! Despite the fact that they are much cheaper than the auto-injector pens & syringes (which have failed to function at least 70% of the time---and then I'm stuck paying for the med, but I can't receive the med).
My dr's office said that even on appeal with a letter from my dr, everyone gets denied
And I went through a similar problem with another med last month, and got nowhere at all, even with the office of the president.
This is atrocious. Our premium went up by 14% for this year, our deductible doubled to $2,000 apiece, our out of pocket more than doubled, our co-pays shot through the roof, big med deductible. What they will cover in meds have been cut back hugely. They cover next to nothing for my out of network drs, in spite of paying for out of network coverage. And next year??
I'm at the end of my rope. I spend so many hours every single blasted day fighting the insurance company and all the other entities I deal with. I can't do it anymore. And what is the choice?? Sorry for the rant, but . . .
Posts: 3771 | From around | Registered: Mar 2008
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Rumigirl
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The other thing is: I don't understand how the FTC allowed this deal to go through (except lobbying, of course), because now Express Scripts has 60% of the market. Can anybody say monopoly? Very, very close. Too close to count that it isn't quite, because essentially, it is.
[ 09-06-2012, 04:00 PM: Message edited by: Rumigirl ]
Posts: 3771 | From around | Registered: Mar 2008
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posted
I have had similar issues...have Medco and my insurance co has already *red flagged* me. I now try and get some of my meds *on my own*...if you haven't, check out some of the survivalist websites. I don't want to say too much as I am not sure what is allowed here and what isn't but let's just say I was able to get what I needed without the hassle.
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Rumigirl
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tofumamama,when they "red flagged" you, what happened specifically? Did they start refusing to authorized rx's?
As an update, I am STILL spending ALL DAY on the phone, for the 10th day, trying to get this ONE rx authorized and filled for a reasonable number of doses. It doesn't end. It's unreal.
Posts: 3771 | From around | Registered: Mar 2008
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posted
I started getting phone cals from *concerned nurses* who wanted to discus any concerns I had with my health. The one and only nurse I spoke to asked VERY leading questions, and after aout 10 minutes I figured out what was going on. As it is, my doc and I agreed NOT to list Lyme as my dx so I could get treatment and he wouldn't be questioned (Not a LLMD)
Posts: 13 | From MA | Registered: Sep 2009
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I've always had major issues with Medco and also wondered if I've been "flagged" as a problem in their system because of "expressing" my frustrations. I've ended up keeping a log of names & dates & information because of the lack of communication within their company. Having to repeated call over & over for the same issues made my blood boil and the log allowed me to document and reiterate things I was told with a little more credibility.
Rumigirl, is your prescription plan through your workplace? Does your work offer Health Care Advocacy? If so, it may benefit you to get them involved. They have turned out to be very useful in my case.
-------------------- ---------- Danni Posts: 311 | From Glen Mills, PA | Registered: Jan 2009
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Rumigirl
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My insurance plan is through my husband's job. But HR there is clueless and could care less. Plus, we don't really want to reveal my health issues and insurance use to his HR dept.
I spent many more hours today on this ONE rx, still not resolved. Each time they say it's resolved, but when the pharmacist tries to run the rx through, it's either not covered at all, or for the same limited quantity as it was before I started fighting it. Unreal.
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Catgirl
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Maybe we should write our attorney generals. This is just insane.
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Rumigirl
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I am STILL working on this one rx, not resolved, getting nowhere. It's been 1 1/2 weeks of hours per day, while I am out of a critical med. And wasting my dr's office's and my pharmacy's time as well during all of this.
Oh, and on the issue of the insurance co's nurses calling to "help," I was distrustful and disdainful of them, too.
But recently, I did speak to one, and did ask for very specific help. Surprise, surprise, the only "help" she was able or willing to do, after asking for a ton of info and time from me, was to tell
me to call a specific government agency for help (thanks!), and to offer to try to see if they could help me get some meds cheaper (read: they want to save THE CO $$). I was so mad that
she wasted A LOT of my time, when there was no way that they were wiling or able to help one iota.
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Rumigirl
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Well, I finally got my answer from Medco/Express Scripts: they are NOT going to increase the allowable dose---after all these hours and days of fighting it. I'm allowed 5 doses per month.
Ironically, the form that I don't want, because it doesn't work, they increased the allowable doses to 8 per month. But it is much more expensive for them to cover (besides the fact the the pens don't function so many times), so why won't they cover more of the vials?? Makes no sense at all.
They said I could appeal it, but my dr's office said that all of the appeals get denied. Whenever I've appealed med decisions before, they've been denied. I've really had it. What a monumental waste of time. The decks are stacked against us, folks!
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sammy
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I'm sorry Rumigirl, that is the exact same experience that I've had with Express Scripts. When they say no, they mean no. You can file all the appeals you want want but your doctor's recommendations will not be considered. So sad, they really don't care about our wellbeing.
My ins only allows 6 generic imitrex tablets per month. Lately I've been getting at least 6 migraines per week.
I understand how debilitating Migraines are. I missed getting to go see my sister and my new baby niece (10days old) last week because I was too sick with a migraine. I haven't been able to hold the baby yet because when I saw her last she was in the NICU.
When I have a migraine I can't function at all.
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Catgirl
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I think you're right Poppy. People just can't connect the dots until something actually happens to them or a loved one. I just don't know where empathy and compassion have gone. I guess it's all about money.
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Rumigirl
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You better believe that it's all about $$!!
sammy, only 6 TABLETS per month?? The generic tablets are dirt cheap!! That's unreal! The Imitrex tablets don't do a thing for me anyway. I need the shots---or occasionally Maxalt tablets---plus other meds.
sammy, but won't they let you fill it more times per month for yet another co-pay? Which still isn't right at all, but would help at least. It's highway robbery. ANd getting worse all the time.
Do the tablets help you much? If not, you probably should try the injections. Not fun, but they work much better and faster.
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lymednva
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I think a lot of it depends on your personal insurance plan. I have excellent coverage and Express-Scripts has been in charge for years.
Using a local pharmacy will cost a lot extra, so unless it's something you are experimenting with new dosages, or not a long term med, it makes sense to bite the bullet and use the mail order service.
They don't view antibiotics as long term meds, even when I take them long term, but it is less expensive to fill them by mail order for 90 days than doing it locally for 34 days at a time.
-------------------- Lymednva Posts: 2407 | From over the river and through the woods | Registered: Apr 2006
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quote:Originally posted by lymednva: I think a lot of it depends on your personal insurance plan. I have excellent coverage and Express-Scripts has been in charge for years.
- I'm hoping that is true!! I have good insurance coverage. We had Medco many years about (10?) .. and it was fine. But things have changed.
I'm a little scared by this! And very frightened to end up with the GOVERNMENT handling our health care.
-------------------- --Lymetutu-- Opinions, not medical advice! Posts: 96222 | From Texas | Registered: Feb 2001
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posted
Rumi... I used to use the shots when they first came out. OUCH!! I would be so debilitated by the headache that I could barely figure out how to do the shot!!!
One time my husband had to read the directions to me so I could do it.
Thankfully, when the pills came out they worked for me. I don't have migraines anymore. (whew!)
-------------------- --Lymetutu-- Opinions, not medical advice! Posts: 96222 | From Texas | Registered: Feb 2001
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Catgirl
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For those of you with good coverage, you have it now, but that doesn't mean you will have it in the future, even if you don't have a government insurance plan. If you think a government plan is so bad, just ask a senior to give up their medicare. No one will do it.
Sorry folks, but socialized medical care has been here for decades. People just seem to be having trouble connecting these dots.
Notice how your insurance is going up? Notice how your deductibles and out of network deductibles are going up? Notice how your co-pays as well as the cost that you now have to pay for the meds is going up?
These insurers are for profit organizations. That means they are going to make money off of everyone. I think we are the only country in the world that allows this (for profit health care organizations). This is something I for one would love to see change.
Healthcare is changing. It's just going in slow motion, so it's a bit more difficult to see what's happening. You can only squeeze a lemon for so long. If we are all paying so much out of pocket for lyme treatment, what do you think is going to happen to every other kind of health related treatment?
I guarantee you everything will cost more. So we will all have to pay for it some how. Either out of pocket, or through taxes. Nothing's free. The choice is yours.
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Rumigirl
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My health plan in recent years won't allow me to get most of my meds through the mail order, which is cheaper. And to boot, they change the rules without notice every couple of months, this med can only be gotten at a local pharmacy, that med only from mail order, etc.
They also keep changing what tier the meds are in and what the restrictions are, ie, needing pre-authorization, supply limit (only can get so many per month), etc.
Once you get a preauthorization or a Quantity Exception, it is supposed to last a year. But often they withdraw the pr-eauthoriztion with no notice, and you're back to square one. It's so unreal.
And more and more of my meds, injectable and IV included, are coming from Mumbai (India), Indonesia, and God knows where else. There is NO oversight in those places!! Arghhh! Who the blazes knows about the quality of these meds??!!
My rocephin, IV pain med, and injectable migraine med---all from Mumbai. Now I've been to Mumbai a lot over many years. Let me tell you, this does NOT inspire confidence! What the blazes can I/we do?
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Rumigirl
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Question: how is Medicare about covering meds? Of course, it depends entirely upon what plan you have and through what co, so I guess no one can say, except for their specific plan/co. It's way, way too complicated. But I do hear that people are happy with it in general.
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Catgirl
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I can't believe I'm still going here with all of this, but I feel compelled to help.
I have a friend who gets her meds covered through medicare. It's more paperwork, sometimes a pain, but it's covered.
The majority of issues you are having happen when we have a for profit health care system. They call the shots. It's only a matter of time before it happens to everyone. People are slow to see this though. They think that their benefits are great, want to keep them, and think it won't happen to them (pipe dream).
I have news for them, their company is for profit too. Just as with lyme treatment: being denied that chronic lyme even exists, the same thing can and will happen for many with health issues, especially the major ones, like some needed surgeries.
They (insurance companies) will tell you what they are going to pay for, and what the rest of us are going to pay for. That's what for profit insurance companies do.
I used to work for a health insurance company. Maybe that's why I can see this. It's here, it's coming, so buckle up. Our best bet is a healthcare for all system, just like medicare. Some seniors currently purchase secondary insurance to cover all the rest that medicare can't pay for. We can do this too.
Unfortunately, the insurance companies have their buddies in congress. And their buddies make it a political issue, when it doesn't have to be. That's why we are here today. Too much money = too much power (sound familiar?).
It's sad to say, much less admit this, but there are many other countries with much better, I mean MUCH better insurance than we have. That's because they are not politically divided on this issue. They take care of their people.
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lpkayak
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catgirl-thanks for coming back. we need a clear brain...at least i do.
-------------------- Lyme? Its complicated. Educate yourself. Posts: 13712 | From new england | Registered: Feb 2004
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Catgirl
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You're welcome. :) I have no problems poking holes in all the rhetoric on healthcare.
Congressmen and women have the best healthcare in the country. My husband and I used to have coverage like this. If anyone wants to change this so everyone has better coverage (90% of us don't have the coverage congress has--which is why they don't want to change it--sound familiar), just call your congressman or woman and tell them how you feel.
Tell them what you want. Because our current system, and the way it's going, is going to screw its insureds (all of us) even more. What's happening to Rumigirl will happen to everyone. And that's just the tip of the iceberg.
I'm sorry to sound like such a fatalist here, but the truth is sometimes difficult to swallow. It's easier to deny it's happening, and just ignore it. It was easy for me to deny I had lyme at first, but eventually it sunk in.
Eventually, when more and more people like Rumi are getting screwed (I'm so sorry Rumi), and the people who currently have great insurance start to notice that their insurance company is slowly denying coverage on certain things and raising their insurance, only then do people begin connecting the dots.
Maybe it will be after they get denied something they desperately need. By then it's too late. It is so hard to un do this stuff. Now is the time to try and change it.
-------------------- --Keep an open mind about everything. Also, remember to visit ACTIVISM (we can change things together). Posts: 5418 | From earth | Registered: Mar 2011
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posted
So when your doctor no longer makes a profit is he going to stay in practice??
"Tell them what you want. Because our current system, and the way it's going, is going to screw its insureds (all of us) even more. What's happening to Rumigirl will happen to everyone. And that's just the tip of the iceberg."
We're saying the same thing, but blaming different sources, I believe!
I say it will all get way worse if we have national health care. Where are all the doctors going to come from?
Where is the incentive to develop new surgical procedures and advancements going to come from if there is no profit? Have you ever run even a small home-based business?? Could you operate with NO profit??
The reason prices are getting higher right now is DUE to the coming iceberg.
-------------------- --Lymetutu-- Opinions, not medical advice! Posts: 96222 | From Texas | Registered: Feb 2001
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posted
It really sucks when insurance companies can dictate our health care and dismiss our doctors� treatment plans. It�s outrageous.
I can offer a few suggestions. All of them take time and effort and require us to be our own best advocates for our healthcare. That�s tough when we�re already sick and fighting for our health, but maybe something here will work:
Many pharmacies accept a variety of discount cards. There are many discount cards available, you can either google, or ask at your local pharmacy.
Many pharmaceutical companies offer discounts if you meet certain criteria. You can try contacting individual companies that produce the medications.
Each state has an Insurance Commissioner. Try this website to find yours. Explain what�s going on for you and see if any support is available: National Association of Insurance Commissioners
Contact your state and/or federal representatives. Many of them have staff that provide support on issues such as this. For example, I was helped by my representative when my applications for student loan discharge due to disability were rejected over and over for years. The representatives helped me with the process, and it worked.
Wishing you the best.
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Catgirl
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I just got back from my acupuncture apt (awesome).
Doctors are no longer making much profit. It's because they are getting squeezed from the insurance companies. That's why they only have fifteen minutes to see you. That's why they just push a pill. They simply don't have the time to spend on their patients anymore. The insurance companies "for profit" are the problem here. They are calling the shots. The doctors need to call the shots, not them.
Doctors made tons of money before our current healthcare system came along (70s-80s). Once we started getting third party administrators is where it all started to unravel. It's really not about the "small business" making a profit thing. Not even close to it. Doctors made so much money back then, that everyone wanted to be a doctor.
But the for profit third party administrators (HMOs,PPOs, etc) came along and offered to "save money" (yeah right), and that's when it all started. So currently, the docs are held under strict guidelines to limit, that's right, limit how they treat you (what they can suggest for you, even though it may be better than what the insurance company wants). Why? Because ultimately it will save the insurance companies money.
So if your doc wants you to have a better drug, he can't even suggest it to you, because the insurance company won't let you have it anyway. Not until they have decided that you really need it (medically necessary). They call the shots, because they are for profit.
The less docs tell you, the less services they have to provide, and the more they get paid. It's called a tiered system, and that's how it works. But if you're on the outside, like the patients are, you have absolutely no idea what's going on.
The incentives for new procedures come from private industry. And doctors aren't going anywhere. If everyone is reimbursed the same, it won't matter. For profit does not belong in a health care system at all. That's why insureds like Rumi are getting denied. That's why everyone will be affected at some point in time. And I guarantee you, if it hasn't hit you yet, it will.
A universal health care system will mandate that patients not be denied coverage, that people will get their meds paid for, and won't get stuck with a $10,000 bill just for going to the emergency room with a broken arm, or even denied a procedure that used to be covered, but now costs $18,000 to do. It will "spread the wealth" with coverage. Unfortunately, our congress people will go from fabulous benefits, to good ones (boo hoo), so that all of us get the same thing, even them (sounds fair to me).
But no one likes change. And they don't want to lose their existing fabulous benefits anymore than anyone else does. So fear is mongering here. Fear and change.
Currently a select few have fabulous benefits. But they don't want to lose them. Congress has the power to keep from losing their current fabulous benefits (our for profit system) because they are in congress. We have the power to change our existing sucky system though.
If everyone calls their representatives and tells them that they are only going to vote for representatives, congressmen, and senators who will make sure everyone has the same thing (like a universal health care system, or medicare for all), then and only then will things improve. Writing them is even more powerful than the phone.
I really hope people can connect the dots. Otherwise, Poppy (above) is correct. I guess it's kind of like lyme--unless you've been denied, you simply don't have a clue what's in store for you.
-------------------- --Keep an open mind about everything. Also, remember to visit ACTIVISM (we can change things together). Posts: 5418 | From earth | Registered: Mar 2011
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poppy
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Countries with universal health pay their doctors a very good salary, and they don't have to have staff people who deal with all these different insurance companies and their rules. There are variations in these countries. Some offer private policies for people who want more or different things.
As for the great deal that Congress members get, this is the same thing that federal employees have. Basically it is a contract that says what will be covered and it is negotiated with several private insurers. The employee can choose which company they want. So, they are still dealing with private insurers, and if they are lyme patients, they still get stiffed.
Posts: 2888 | From USA | Registered: Mar 2004
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As for the great deal that Congress members get, this is the same thing that federal employees have. Basically it is a contract that says what will be covered and it is negotiated with several private insurers. The employee can choose which company they want. So, they are still dealing with private insurers, and if they are lyme patients, they still get stiffed.
- exactly ..nothing will change for us .. in my opinion...
--Catgirl said:
"Doctors made tons of money before our current healthcare system came along (70s-80s). Once we started getting third party administrators is where it all started to unravel. It's really not about the "small business" making a profit thing. Not even close to it. Doctors made so much money back then, that everyone wanted to be a doctor."
I remember when that happened. What a screw job. My Dr is still independent. He works for himself. He is NOT rich because he gets very little money for all of the Medicare patients he has. (he's not poor either! )
I think he's always happy to see me since I have private insurance!
I worry he will quit if we go to a national plan. Drs will not be paid very well.
-------------------- --Lymetutu-- Opinions, not medical advice! Posts: 96222 | From Texas | Registered: Feb 2001
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posted
I have express scripts too but so far haven't seen a change in how they are filling my prescriptions. Sounds like they are getting too big for their britches.
-------------------- Faithful
Just sharing my experience, I am not a doctor. Posts: 2682 | From Colorado | Registered: Oct 2009
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Rivendell
Frequent Contributor (1K+ posts)
Member # 19922
posted
I have express scripts and haven't had any problems so far.
Some meds, like zithromax, they will only fill for 7 days, then the pharmacy puts in a request for more, and express scripts always alows the zithromax. I can only buy 7 at a time, but still get all of it each month. does this makes sense, brain fog and all?
I've never had much faith in "for profit" anything. But there are problems no matter what system is used because people always get sucked in by greed and power (I mean people running the show.)
So what do we do about the addiction to greed and power?
This ends up being a philosophical/spiritual problem.
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