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    Monday, August 20, 2007

    The Pharma Benefits Dance: Mr. Dr. SS at Health Care Renewal got the go around when he tried to figure out how to appeal a drug denial by his pharmacy benefits management company (aka Medco):

    When I went to my neighborhood pharmacy a.k.a. megastore, I was told my health plan did not cover this medication. I possess a BC/BS PPO and Medco card through my employer, a university. The cost of a month's supply of the medication was approximately $160. The pharmacist suggested I contact Medco to find out why Meridia was not covered.

    ...A Medco representative told me Medco is only a contractor and plan administrator to "my insurer" and does not make such decisions. However, the rep did not know who did.
    I next contacted BC/BS. Their rep told me they only covered medical care and not medications, and suggested I call Medco. When I mentioned Medco told me they did not make such decisions, the BC/BS rep had no suggestions.

    I called Medco back. The Medco rep this time told me I could appeal the denial and was sending me an appeal form that I should mail back to - Medco. Now, I was really confused.
    I inquired why Medco gets an appeal form for denial of coverage if Medco did not make the decision. The rep did not know. I asked for the name of a person at the organization where the form would go. Again, the rep did not know.

    I finally called my university's benefits management contact, yet another contractor company (it seems everything is handled by third parties - just a little bit of administrative overhead there?), and that is where this already confusing matter took a very deep turn directly south.
    The rep at the university's Benefits Management contractor said that he believed Medco was the responsible party. I informed him Medco said they were not.

    In the first actually creative and industrious response from any of these organizations, the rep said he would get a Medco representative on the phone in conference call mode so we might get to the bottom of this.

    We got to the bottom all right. The real bottom.

    The Medco customer service rep that the University Benefits Management Rep conferenced in was a new individual, not the ones I had spoken to prior. This rep repeated that Medco was just a benefits manager and was not responsible for the denial.

    I asked the university's Benefits Management contractor rep if he believed that was the case. He was as confused as I. The Medco rep said I needed to appeal.

    I asked the Medco rep for the name or identity of a person or organization where the appeal form would go, so I could contact them directly, as I was a medical doctor with pharma experience as well and wanted to go direct to the source.

    The Medco rep replied that "my title would not get me advantage in this matter" or words to that effect.

    And it didn't. He never really ever got an answer.

    But truly, it is Medco what makes those decisions. That's why they are called a pharmacy benefits manager. The insurance company is paying them to manage this stuff for them.

    For the lay reader - if this happens to you, nicely ask your pharmacist to give your physician a call. He and your doctor can either put their heads together to come up with a covered alternative or he can give your doctor the number to call for an appeal. At least, that's how it usually works at my office.

    There are times when it doesn't work this way. Sometimes the pharmacist is too busy or too uncaring to intervene or it may be a pharmacy tech who tells the patient about the denial and doesn't know anything but what the computer message tells her to say. If that's the case, then call your doctor to tell him about the denial. It's usually just a matter of calling the pharmacy benefits company and requesting a pre-authorization form be faxed over to the doctor's office.

    The key is not to ask any detailed questions of the workers on the phone chain-gang. They don't know who will be responsible for making a decision or who will be getting a form. But they do know how to fax those forms.

    Yes, it's a pain to have to make these phone calls and to have to fill out forms and send faxes. And a lot of it could be avoided if the companies made their formularies easier to access. But, my experience has been that even with the notorious Medco, the turn around for approval is 24 hours or less.

    posted by Sydney on 8/20/2007 07:51:00 PM 0 comments


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