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Thank you for the reply christine5. I certainly agree. The policy across the board has me astounded. The grocery,retail and drugstore chains came to this conclusion together? I'm not sure if the mail order pharmacy's are following the same policy. Finding a local pharmacy to fill this is not the solution. My insurance views this as out of network. So I pay twice as much. I agree with you. I have a script from my doctor that states I take this specific amount every month. Why are the retailers allowed to manage my healthcare?
Replies to "Thank you for the reply christine5. I certainly agree. The policy across the board has me..."
Hmm, I wrote a pretty long reply last evening - pushed send, but my finicky network failed to send, and now it is lost.
Please don't blame the pharmacist/retailer. Aside from deciding which drugs they will carry, they have no authority. If they receive a prescription for a medication they have, they make a good faith effort to fill the order.
When a pharmacy tries to fill a prescription, and submits it for coverage, they get back "approved" or "denied" (and maybe an explanation of why.) Now comes the most frustrating part. Insurance companies use a pharmacy benefits manager (PMB) to develop their Formulary - what drugs they cover, how many, the cost and what conditions they impose. That same PMB then enforces the rules, often denying or limiting coverage for medications we have taken for a long time. And every time we have a policy change, there may also be a new Formulary, new PMB and new rules - sometimes even in the middle of the year.
How do you deal with this? Instead of calling the doctor or pharmacy, whose hands are tied by the PMB, contact the customer service number on your insurance card for assistance.
Keep good records of every conversation. Find out how to get from "No" to "Yes" - is there an exception process, does your doctor need to send them a letter?
Still "No" - find out the appeal process. If you are on Medicare and the insurer denies you, there is a two level process, with very strict timelines for a decision.
Is this a good process? Not in my opinion! People are suffering from lack of medication; many do not have the time, energy or knowledge to protest.
We have gone through this rigamarole 4 times this year, and ultimately we got our meds every time. LOTS of wasted time and money. I am currently engaged in writing letters to my insurance company, the PMB and Medicare, copying in my senators and representatives, to try to start the ball rolling to get this changed. But alone, I am pushing a very large boulder up a steep hill. Be sure to share your hardships and frustration with your elected representatives, who are in a position to change things.
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This is a disgrace. I am so sorry. In my case, my insurance manages my health care. The doctor orders my prescription and either my insurance or my pharmacy controls how many and when I get my meds. No wonder doctors are leaving in droves.