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Author Topic: Aetna moves Complera to its own mail order program starting Jan 2015  (Read 1095 times)

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Offline tealeaf

  • Member
  • Posts: 39
Hi folks,

I've got a letter from Aetna saying Complera will be moved to its Specialty Pharmacy Benefit program. I have to get my doctor to subbmit a request for the drug and they will approve it and ship it from their mail order pharmacy. Every month, 10 days before the new order, they will call and ask if I still need it (or still alive) and approve it for shipping.

What a load of crap. There's no way around it either. I don't see any mention of it accepting the copay benefit program so I might end up paying for it now.

And I have the best plan with Aetna too. It's Open choice PPO.

They're certainly taking away a choice in the guise of making sure we're taking the correct drugs, correct dose and all that jazz.

As a side note, it's my third year on Complera and I'm having no side effects so far. Kidney and liver numbers are good. CD4 is at 500, 600 range. This drug has been a great fit for me.

Just had to vent. Does anyone use Aetna mail order pharmacy? What's your experience like?

12/05/2011 - tested positive
12/14/2011 - CD4 376 (18%) - VL 45734
12/28/2011 - CD4 367 (17%) - VL 27000
01/05/2012 - started Complera
02/08/2012 - CD4 521 (31%) - VL 226
04/05/2012 - CD4 453 (22%) - VL 44

Offline db3hs

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  • Posts: 1
Re: Aetna moves Complera to its own mail order program starting Jan 2015
« Reply #1 on: December 23, 2014, 11:05:27 PM »
Hello all & Tealeaf:

I did not receive a letter for Stribild, although I didn't begin cART until October 31 of this year. Diagnosed September 11, 2014.

I did, however receive their joke of a mailer for "changes in prescription drug coverage for 2015" which included a list of all medicines with reflected changes for 2015. I was not on treatment at the time, so I cross referenced nearly every cART medicine, subsidiary components, and the various mono-pills. Long story short, nearly every ARV med was switched to specialty pharmacy. Or, so I presume given that the chart they sent in the mailer included abbreviations that were not explained in either the header or footer. I have repeatedly informed Aetna of this incompetence and irresponsible business practice.

I have placed approximately 5 calls in the past 2 weeks trying to get them to confirm if indeed Stribild would be restricted to specialty pharmacy only, if I would be able to use my copay assistance still. They keep stonewalling and saying information won't be available until January 2 (Friday). I am due for my refill on January 5 (Monday). I have expressed my doubts at their ability to process mine and however many other's pre-authorizations on a Friday after New Year's and ensure that I receive my refill in time. To complicate matters, I am a PhD student preparing for my comprehensive exams which will begin on (take a guess?) Monday, January 5.

I am on the Aetna Student Health plan which is "self administered" by my university (and employer). So, I may have a slightly different situation than others with Aetna.

I have also informed them of my knowledge of the Consumer Watchdog federal lawsuit filed against them in San Diego recently, and that I fully intend to continue refilling my prescription at my preferred local retail pharmacy.

My anxiety level is high. Who knows if this is reasonable or not. However, at every turn in each of my 5 contacts with them they have provided me inconsistent information. "Yes, you will be able to refill at a retail pharmacy." "No, you will not." "Who knows? The Member Services Department is closed for the Christmas holiday."

I am not pleased, but I am persistent and I refuse to be jacked around. End of story.

I will update accordingly when I have more information.

Good luck & good health to all involved in this giant mess.

Offline ChavinKnight

  • Member
  • Posts: 36
Re: Aetna moves Complera to its own mail order program starting Jan 2015
« Reply #2 on: December 24, 2014, 09:47:06 PM »
At the risk of sounding hysterical, I again return to the forums to beat what should be a dead horse, but alas, one that simply refuses to die.  The problems with mail order and so-called specialty pharmacy are too numerous to mention.  The United lawsuit spells it out in exquisite and articulate detail.  I absolutely love Jerry Flanagan and the work that he is doing; I've also had the pleasure of speaking with him by telephone. 

In any case, the first question is who is administering your prescription drug benefit (Express Scripts, CVS Caremark, etc.)?  The basic strategy to deal with this is 1) file a grievance citing the privacy and safety concerns, i.e., you are at risk of your medical condition being revealed if you are forced to use mail order, you are at risk of missed doses, you have concerns about medication being exposed to temperature extremes, etc.  Include a copy of the United lawsuit.  Copy Consumer Watchdog and ensure that you note on your correspondence that you have sent said copies.  They will still probably deny your request to use a retail pharmacy.  2) File a second level appeal.  This will either be with your pharmacy benefit manager, or it will be with your plan administrator (your university/employer benefits program office).  This obviously represents a violation of your privacy, but you will get a response.  Hopefully, this will be the end of it and you can opt out of mail order/specialty pharmacy.  Be articulate.  Be relentless, but polite (hard to do at times).  Again, copy Consumer Watchdog.  If you are denied by your plan administrator, then you seek an outside review of your case.  Should that fail, I believe litigation is the next step.  No one wants to go there.

These steps may vary from person to person depending on their particular plan, state of residence and so forth, so you will need to inquire specifically as to what the grievance process is.  Follow it and the timelines.  Do not accept that the problem has been addressed unless and until you see it in writing.  The response that you are getting (conflicting and directly contradictory) is unequivocally unacceptable under any circumstances.  Period.

Understand this--They place numerous hurdles in your way, hoping that you will give up, or are too busy (or too sick) to fight and advocate for yourself.  If they see that you are not going away, they are likely to work with you.  But you will get many "NOs" along the way.  DO NOT be dissuaded by this....just patiently move forward.  You should also consider complaints to the Office of Civil Rights and to the Board of Pharmacy (for reasons related to the mail order issue that I would be happy to spell out further).

Also, articulate the problems that you are having (lack of transparency in the grievance process, inconsistent information, unable to reach someone that you can discuss the issue with and who can resolve it, etc.).  I have had numerous representatives tell me that what I was seeking was impossible, even after I had already obtained it.  It is NEVER the case that you are permanently stuck with mail order and/or specialty pharmacy prior authorization nonsense.  However, they want you to believe that.  They are not interested in your health or emotional well-being, only the money.  You have a self-funded plan.  Your employer/university is paying for this, and they have the right to demand an override for you, since it is their money, not Aetna's and not the PBM's.  And they want you to be healthy, because that makes you a better student and employee.

I am sorry that you are having to fight.  However, if you do so, you will help not only yourself, but also someone coming after you who does not have the same strength or ability to verbalize the problem.  It is worth it.

I empathize with your struggle.  Comprehensive exams are difficult enough without this on top of them.  I'm glad that I didn't contract HIV while I was in graduate school.  You sound articulate and clear, so I doubt that you will need any help advocating for yourself.  However, if you would like to hear about my struggle and the resolution that I have obtained, please feel free to PM me, and we can compare notes.  Most people simply give up before the finish line.  My advice is don't do that...slow and steady wins this race. 


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