POZ Community Forums
Meds, Mind, Body & Benefits => Insurance, Benefits Programs & HIV => Topic started by: Jody on July 08, 2013, 09:45:54 pm
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This is specific to New York state residents but maybe helpful to others...An online user had this to say...
My insurance carrier forced me to order meds from out-of-state pharmacies. After some initial confusion and about a week, I was finally able to get my meds.
If you are being obligated to use mail order and are experiencing problems because of this please contact:
Chris D'Ippolito,
NY State Attorney General's office,
Health Care Bureau
Tel: 518-486-9744
Fax: 518-402-2163
Mandatory by mail after a few fills of maintenance medication is becoming the norm. Your employer saves money this way by using a mail order pharmacy that buy mega-huge amounts of medication directly from the manufacturer at volume discount prices.
Here is what you can do:
If you have an outside agency paying full or partial amount of your copay for HIV medications (Ryan White, charitable foundation, etc) that gets billed directly, you need to ask for a coverage appeal/override directly to the mail-order pharmacy to be able to get those specific meds from your retail pharmacy because it would be a financial hardship and without doing so would not allow you to continue your treatment.
If you have "copay assistance cards" sponsored by the manufacturer that the mail order pharmacy does not accept you have 2 options. Call the 800 number on the back of the card and request "direct reimbursement" forms. You will have to pay up front and then submit for reimbursement. If that is not a viable option, use the previous method of getting coverage appeal/override as described above.
Chris D'Ippolito, has been working with people who have had difficulty accessing their medications (specialty medications) because they have been forced into mandatory mail order pharmacy. Chis is willing to work on a case-by-case basis and encouraged clients to call if they have a compelling situation.
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Thanks for the post. Good info. I'm in this situation right now: my insurer says Isentress refills can only be done by one particular mail-order pharmacy. Unfortunately they did not bother to inform me of this until the last minute, so now I'm scrambling to get it set up. Oddly enough, I can still get Truvada from a retail pharmacy, as they're not considering it a "specialty" drug.
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As someone mentioned in a previous thread, you should demand the mail-order only requirement in writing. They should be able to produce the policy and send it to you. If not, it doesn't exist and you might be able to use that to your advantage.
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I am also just now fighting this mail-order requirement with Anthem Blue Cross/Blue Shield and OptumRX. I have contacted my employer benefit administrator, she is not aware of the "specialty" designation, only to tell me that there are others who have not received the initial letter stating OptumRX was the only method of obtaining my HIV medications. This popped up last month, it was over-ridden, now it's rearing its head again this month. I am healthy and am fearful that delays, potential theft, and incompetence will cause delays in my regimen. I am in Ohio....is there a source with the Ohio attorney general's office addressing this? Is anyone else in Ohio dealing with this issue?
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There is an article in Poz today about this http://www.poz.com/articles/mandating_mail_order_2791_24350.shtml
As far as Anthem goes, the state of California sued them to stop the practice but it only affects California, not Ohio. I would suggest contacting your states insurance commissioner. There are some groups working to fight this (noted in the article) that may be able to assist.
This scares the shit out of me. My insurance company has called me asking me to switch to mail order, I told them no and to not call me again. Sor far they haven't forced the issue. I'm hoping they don't but that doesn't seem to be the way things are going.
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Thank you, I noticed that immediately AFTER I had received the email from my employer's benefit administrator, telling me basically I had no choice. My co-payment jumped from $30 to $75 per month, which also irritates me. Fortunately I am healthy and gainfully employed. The increased fee will hurt a bit, but I'll just have to cut down on a couple of porn sites (LOL...the sacrifices we must make!). I noticed there is a complaint on OptumRX with the Attorney General of Ohio, I requested via public disclosure all information on the complaint. I will check with the state insurance czar (whoever that might be).
I also fired off a cut and paste email of the POZ article to my employer's benefit administrator and let her know I had contacted the Ohio Attorney General's office. Now, I'm a realist and don't expect much, but at least my conscience is clear and perhaps, just perhaps put a small sinking feeling in the stomach of my health benefit pencil pusher.
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Personally, I love the mail order option. I have used it for years - even before "mandated" for ALL "maintenance" drugs in my plan (not just Specialty). The extra time allowed for refills have allowed me to build a 9 months buffer supply of all my drugs. This has included 3different mail order pharmacies
In the 7ish years of using mail order, I have had only two instances of slow delivery - really not much difference than delays for out of stock in store Rx experiences.
Mike
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Personally, I love the mail order option.
I do too, except that ExpressScripts (formerly Medco, formerly a lot easier to deal with) doesn't accept copay assistance program payments like my local pharmacy does. Copay assistance covers $350/mo for me that I would have to lay out myself until I was reimbursed if I had to fill my HIV meds through the mail-order option.
I'm a cheap SOB. I want my money working for me. I shouldn't have to loan it to a mega-corp who has the ability to receive payment from these assistance programs. If anything they have a better payment infrastructure than local pharmacies do. It should be easier for them to handle copay assistance programs.
They don't have any reason not to, except that they don't want to. If ExpressScripts would accept copay assistance as partial payments, I'd switch over to mail-order on my HIV meds.
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I use a local pharmacy.
Every time I go in they ask how I am doing. They ask how I am feeling. They ask to make sure I have enough medication to last me until my next refill.
When I call, they recognize me and ask how I am.
They handle all my insurance and copay and my medical reimbursement card issues.
They genuinely care. And they mail me my meds each month for free.
I highly doubt a mail order company could give a fig.
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This is a nice, informative post, OP.
I almost had to deal with this issue when I had private insurance. I've switched to the public option (haha), and the place I go now calls me if my prescription comes in early. They'll even deliver if I can't make it. I go in, though, because I like to go to the pharmacy. The pharmacist loaned me a book recently, and I need to return it. You don't get that from mail order!
Good luck to everyone fighting this. It's nice that some people find it more convenient, but it should be a choice, not a requirement.
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This is a nice, informative post, OP.
Good luck to everyone fighting this. It's nice that some people find it more convenient, but it should be a choice, not a requirement.
Yes.
Sounds like a corporate monopoly to me. Guess the government can actually do some things right.
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If you take one or two medications daily then mail order isn't a big deal. If you're like me and take a dozen prescriptions, plus frequent short-term prescriptions (post-surgery and what not) then it's not ideal.
Then there's the fact that I live in an non-doorman apartment building on a high pedestrian boulevard -- not ideal for leaving something worth a lot of money on the front stoop if I'm not at home for a delivery.
Anyway, since I obtain medication on a public program (though it's Medicare Part D, not ADAP) I'm only allowed one month's supply at a time, and can only order each month's supply five days in advance.
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Anyway, since I obtain medication on a public program (though it's Medicare Part D, not ADAP) I'm only allowed one month's supply at a time, and can only order each month's supply five days in advance.
I have Medicare Part D and I get most meds 90 day supply.
I do agree about the mail order. I take quite a few meds, as you do, so the mail thing would not be beneficial.
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I have Medicare Part D and I get most meds 90 day supply.
I do agree about the mail order. I take quite a few meds, as you do, so the mail thing would not be beneficial.
hmm...
I will be on Medicare (I hope) and wonder why the difference between you and Miss P.? Is it a state issue?
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Express Scripts, after 3 fills on any prescription (HIV or otherwise), requires mail order. It is a lot cheaper, but I totally get the issues that some people have with it and the desire to stay with a pharmacy option.
What Intaglio describes is particularly troubling. I was going to hope to look into copay assistance. They are probably resistant to it because...well...I don't know...because it's easier to just screw you out of your copay assistance plan?
As a newly diagnosed person I worry a lot about insurance and prescription benefits, and losing them, or them hassling over the things I will need. Glad I have this forum with a wide range of experience in handling all this stuff.
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Express Scripts, after 3 fills on any prescription (HIV or otherwise), requires mail order.
I have ExpressScripts and get all three of my HIV meds, Epzicom, Presista and Norvir, filled locally. I'm able to use copay assistance on all three. I have other meds I have filled through the mail-order option, mainly because there's no copay assistance for them and they're cheaper.
ExpressScripts sent me a generic letter telling me I had to use the mail-order option for my maintenance meds. But they do not require me to use the mail-order for these three.
I have my prescription coverage through BC-BS through my wife's employer, an international company with a lot of clout when it comes to contracting insurance coverage. YMMV.
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hmm...
I will be on Medicare (I hope) and wonder why the difference between you and Miss P.? Is it a state issue?
Maybe I can pick up 3 months worth and don't know it -- before Medicare Part D arrived I was on ADAP and that was always monthly, plus there is one prescription that Part D doesn't cover for me so my secondary insurance, which is Medicaid, picks that up and maybe that's restricted to monthly.
I don't have to get scripts each month, each prescription is for four months before they have to call it in to the doctor, it's just that I can only pick up 30-day supply for each thing. In some ways it sucks but after 20 years I am used to it, plus the pharmacy is only two subways stops away and then a mere one block walk. And it gives me an excuse to stop in the Samson Cinemas for a quick blowjob in the video booths.
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I have ExpressScripts and get all three of my HIV meds, Epzicom, Presista and Norvir, filled locally. I'm able to use copay assistance on all three. I have other meds I have filled through the mail-order option, mainly because there's no copay assistance for them and they're cheaper.
ExpressScripts sent me a generic letter telling me I had to use the mail-order option for my maintenance meds. But they do not require me to use the mail-order for these three.
I have my prescription coverage through BC-BS through my wife's employer, an international company with a lot of clout when it comes to contracting insurance coverage. YMMV.
That's good to hear. Perhaps my experience with Express Scripts requiring mail order (or else dramatically increasing your at-the-pharmacy co-pays) has to do with what my employer requires, rather than Express Scripts itself. At any rate I'm not sure why mail order makes things cheaper for them.
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I'm not sure if it would be considered mail order, but we were put, with our permission, on a "specialty" division of our pharmacy. It's only available for less than 1% of medications, which covers Mim's HIV meds, but nothing else. I actually prefer it over the regular pharmacy. A representative calls the house every 21-24 days and asks if we're ready for a refill. Then they arrange Fed-X delivery which comes the next day. They bill both insurance companies, and even contacts the doctor when we need a refill. We were switched a couple of years ago and now have a 3 month buffer stash of her meds.
That said, there was one incident that I didn't like, but it only happened once. Someone called from the specialty pharmacy claiming to be a pharmacy doctor. He inquired about Mom's health, including her vl ant t's. I told him that she had a doctor that took care of her labs and that I would not discuss anything about her to an unknown entity. We discussed it with her doctor who said that pharmacy doctors were becoming more common. Their job is to make sure that the meds prescribed are necessary and successful. Either way, never got another call like that and we weren't kicked out of the program.
Mum
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Here's how to check if ExpressScripts requires you to order a med from their mail-order pharmacy or you can get it filled locally.
Log into your account. Choose the Price a med in the list of links on the left-hand side of your account window.
(http://i.imgur.com/P2RKf0E.jpg)
Search for one of your HIV meds. Choose the drug strength from the list that comes up and click Continue. Fill in your quantity and day's supply and click Continue.
You then should see a screen like this if you are NOT required to fill the script through the mail-order pharmacy:
(http://i.imgur.com/q9unCKk.jpg)
You will see something like this if you ARE required to fill the script through the mail-order pharmacy.
(http://i.imgur.com/vxts0uc.jpg)
If you are required to use the mail-order pharmacy for your med, a screen-cap of the messages shown will be what you need to submit to the pharmaceutical company's copay assistance program with their forms.
There is usually a customer service number somewhere in the literature you received from your ID doc that you can call. The CSR can tell you how to go about submitting requests for copay reimbursement.
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People often talk about how much savings there is in buying from a mail order pharmacy. I've never seen much evidence so I thought I would post the prices charged from my most recent delivery by CuraScript.
90 Days Supply:
Isentress: $3,343.16
Truvada: $3,807.62
Total annual cost for both meds: $28,603.12
Does anyone here taking these meds know what your pharmacy (mail order OR brick and mortar) charges?
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My costs for going in-person to a pharmacy for those two medications are (30 day supply):
Truvada $1,204.24
Isentress $1,057.52
Total annual cost for both meds: $27,141.12
Quelle surprise! It's actually cheaper to get 30-day supplies at a local pharmacy then being forced to obtain them by mail order. And note, this isn't just any local pharmacy it is specifically an HIV-related specialty pharmacy that works closely with my HIV clinic.
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I have a bill to pay right now for a $79 copay for diabetes testing supply's from the mail order company I was forced to go to . I'm going to call and find out why its so much more than what I have been paying but I'm waiting until next payday . I'm not happy so far with the mail order thing .
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My costs for going in-person to a pharmacy for those two medications are (30 day supply):
Truvada $1,204.24
Isentress $1,057.52
Total annual cost for both meds: $27,141.12
Quelle surprise! It's actually cheaper to get 30-day supplies at a local pharmacy then being forced to obtain them by mail order. And note, this isn't just any local pharmacy it is specifically an HIV-related specialty pharmacy that works closely with my HIV clinic.
hmm...
It doesn't come as a surprise to me.
I hope to hear from more people with whatever meds. Mail order or not.
Jody, I hope you don't mind this tangent on the subject.
Just wondered if the "savings" in health care costs are real or a manufactured myth.
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Epzicom - my final monthly cost for this is $0.00 due to copay assistance.
(http://i.imgur.com/2SGd6yu.jpg)
Norvir - my final monthly cost for this is $5.00 due to copay assistance.
(http://i.imgur.com/I7EoV02.jpg)
Prezista - my final monthly cost for this is $0.00 due to copay assistance.
(http://i.imgur.com/KS0ucBT.jpg)
Truvada -recently replaced by Epzicom due to adverse creatinine levels.
My final monthly cost for this was $0.00 due to copay assistance.
(http://i.imgur.com/KR2ZKYU.jpg)
I pay $5.00/month OOP for the three maintenance meds. This makes my three-month expense a whopping $15.00.
If I had no copay assistance, my OOP/month would be $424.11. A ninety-day supply would cost me $771.99 OOP or $257.33/month OOP, a savings of $166.78 or $55.60/month.
If the Prezista was available through the mail-order pharmacy, I'd save one month's OOP expense every three months. But since I'd have to buy the Prezista locally each month, my savings is less (one month's cost of Epzicom and one month's cost of Norvir only).
All of the "TotalCost" values listed for the three drugs I use are less than what appear on my Walgreen's paperwork. I have no idea if the values on the Walgreen's paperwork are the prices they have contracted with ExpressScripts or not. I really think the values have no basis in reality. They're just made up to make it appear my insurance is saving me more money than it is. ::)
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Just wondered if the "savings" in health care costs are real or a manufactured myth.
I seem to remember reading several comments following some of the recent articles and blogs on this subject (both at poz and elsewhere) where people had discovered that when they were forced to go mail-order, the retail price of their meds suddenly went up.
Most, if not all, of these mail-order pharmacy houses seem to be run/owned by the insurance companies they serve. Call me a cynic, but it looks as though it's just another way for them (ins co) to increase their profit margin, by artificially inflating the retail price of meds. I'm admittedly no economist or accountant - hell, anything beyond basic maths escapes me - but something smells rotten.
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I seem to remember reading several comments following some of the recent articles and blogs on this subject (both at poz and elsewhere) where people had discovered that when they were forced to go mail-order, the retail price of their meds suddenly went up.
Most, if not all, of these mail-order pharmacy houses seem to be run/owned by the insurance companies they serve. Call me a cynic, but it looks as though it's just another way for them (ins co) to increase their profit margin, by artificially inflating the retail price of meds. I'm admittedly no economist or accountant - hell, anything beyond basic maths escapes me - but something smells rotten.
This!^
That is exactly what I was thinking. I heard a long time ago from I firget where that Anthem owns CuraScript. Still don't know how they are allowed to get away with it. OH.... yes I do!!
(http://i1341.photobucket.com/albums/o745/mjm711/nicethings_zpsbd80181b.jpg) (http://s1341.photobucket.com/user/mjm711/media/nicethings_zpsbd80181b.jpg.html)
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Express Scripts, after 3 fills on any prescription (HIV or otherwise), requires mail order. It is a lot cheaper, but I totally get the issues that some people have with it and the desire to stay with a pharmacy option.
What Intaglio describes is particularly troubling. I was going to hope to look into copay assistance. They are probably resistant to it because...well...I don't know...because it's easier to just screw you out of your copay assistance plan?
As a newly diagnosed person I worry a lot about insurance and prescription benefits, and losing them, or them hassling over the things I will need. Glad I have this forum with a wide range of experience in handling all this stuff.
I not sure but I think they may have dropped this requirement.
I'm on a federal PCIP:
http://www.pciplan.com/
They use express script also. In the material I got it states "Effective February 15, 2013, you can get your formulary and generic prescription drugs at a retail pharmacy even after the first two fills"
I use a local Rite Aid Pharmacy.
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People often talk about how much savings there is in buying from a mail order pharmacy. I've never seen much evidence so I thought I would post the prices charged from my most recent delivery by CuraScript.
90 Days Supply:
Isentress: $3,343.16
Truvada: $3,807.62
Total annual cost for both meds: $28,603.12
Does anyone here taking these meds know what your pharmacy (mail order OR brick and mortar) charges?
The price "charged" by a pharmacy and the price actually "paid" by the insurer is very often completely different. Usually a provider charges a standard charge, but will only be paid for the negotiated price.
I pay a much lower co-pay for the mail order pharmacy. Logically, this tells me that my insurance company has a better negotiated price, else why would they force me to pay less and for them to pay more?? Especially when I know my company is self-insured, so Aetna negotiates the prices, but my employer pays the bill. trust me when I say that this company would not be willing to pay more than then need to pay.
Mike
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I seem to remember reading several comments following some of the recent articles and blogs on this subject (both at poz and elsewhere) where people had discovered that when they were forced to go mail-order, the retail price of their meds suddenly went up.
Most, if not all, of these mail-order pharmacy houses seem to be run/owned by the insurance companies they serve. Call me a cynic, but it looks as though it's just another way for them (ins co) to increase their profit margin, by artificially inflating the retail price of meds. I'm admittedly no economist or accountant - hell, anything beyond basic maths escapes me - but something smells rotten.
My insurer is Aetna, my Mail-order pharmacy is Caremark -- owned by CVS. So, this isn't a universal truth. I try and stay away from the big conspiracy idea..... And, as I just pointed out -- the "retail price" rarely matches what an insurance company pays -- they get discounts when negotiated based on volume of business they can send that way. That is where the savings come from.
M
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The price "charged" by a pharmacy and the price actually "paid" by the insurer is very often completely different. Usually a provider charges a standard charge, but will only be paid for the negotiated price.
I pay a much lower copay for the mail order pharmacy. Logically, this tells me that my insurance company has a better negotiated price, else why would they force me to pay less and for them to pay more?? Especially when I know my company is xylophonist, so Etna negotiates the prices, but my employer pays the bill. trust me when I say that this company would not be willing to pay more than then need to pay.
Mike
I understand the negotiated price thing but your point is moot when the insurance company owns the pharmacy (common but not universal). They profit in 2 pockets. If one pocket makes less, the other pocket makes more.
My insurer is Etna, my Milder pharmacy is Caremark -- owned by CVS. So, this isn't a universal truth. I try and stay away from the big conspiracy idea..... And, as I just pointed out -- the "retail price" rarely matches what an insurance company pays -- they get discounts when negotiated based on volume of business they can send that way. That is where the savings come from.
M
I'm not sure if you are required to get your melds through Caremark but it strikes me funny that since Caremark is owned by CVS that they wouldn't let you buy your melds at any CVS store. The "volume" concept doesn't seem to have any logic in this case.
I can't imagine that large pharmacy chains like CVS, Walgreen's, Walmart, etc. can't compete due to "lack of volume" as compared to mail order pharmacies.
It just doesn't add up.
They all (insurance companies, pharmacies, hospitals, etc) make it all so mysterious by not being open with what they charge. Another good reason to get the many insurance companies out of healthcare. The government could easily negotiate the best prices from the drug companies and pass the savings down to everyone. The same thing could be said about many other parts of the healthcare system.
Each sector of healthcare in this country is driven by profits before concern about patients being able to afford care.
IMHO, every sector of our healthcare system "conspires" with the folks in Washington.
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Here is a little ditty about mail order pharmacies that should curl anyone's toes.
http://www.policychoices.org/pharmacy_benefit_managers.shtml
And this.
http://www.rxchoiceandaccess.com/2013/05/06/national-coalition-applauds-taxpayers-protection-alliance-for-exposing-the-expensive-truth-behind-mail-order-pharmacies/ - 23k
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Oh, and I was mistaken. Curascript is owned by the giant PBM ExpressScript.
Consumer choice has gone by the wayside. (except in a few states)
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I also live in NY and I take 18 different medications, I use optum RX and in the beginning I was not happy with them, every time my doctors faxed prescriptions optum never found the so the had to be re faxed 3-4 times but now I think it's ok, you get refill when you have 1 month of medication on hand, so there is no risk to run out.
I take 4 Meds from a local pharmacy and I can't get refill before I'm done with the month on hand. I have more problem with the local pharmacy but since 2 of the Meds are controlled drugs and I get a new script every month I have to take them locally.