Meds, Mind, Body & Benefits > Insurance, Benefits Programs & HIV

For those being forced into Mail order pharmacy refills

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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.

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.

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.

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 there a source with the Ohio attorney general's office addressing this? Is anyone else in Ohio dealing with this issue?

There is an article in Poz today about this

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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