Wednesday, August 13, 2008

New Healthcare Plans ... Part 2

A while back, I wrote about how my company had decided to change healthcare providers. While I wasn't exactly jumping for joy over that decision, I didn't have any choice in the matter, and tried to make the best of it, viewing it as an opportunity to make some changes I had long put on the back burner.

One immediate benefit I could see (a silver lining of sorts) was the fact that Oxford/United Healthcare had recently switched lab providers from Quest to LabCorp, and LabCorp had almost no locations in the NYC area. LabCorp quickly signed a deal with New York City's largest pharmacy chain, Duane Reade, but since I work in the suburbs and LabCorp had only a few suburban locations at the time of the switch, until they got around to adding facilities, getting my bloodwork done had grown to be, putting things mildly, a pain in the @$$. I don't relish the idea of going to a pharmacy to have bloodwork done anyway amidst shoppers loading their carts with Pampers and other things found in a drug store, but the biggest issue was that most of the Duane Reade "collections facilities" as they are euphemistically referred to, do not offer Saturday hours.

My biggest issue (or at least that's what I thought would be) was that my long-term endocrinologist was not on the list of preferred providers, and frankly, I tend to view my endocrinologist (which is actually considered a "specialist") as my primary care physician (PCP) since I almost never see my PCP anyway, whereas I visit my endo once per quarter like clockwork -- getting the usual bloodwork, checkup, plus refills on all of my prescriptions (for test strips, pen needles, insulin, my ACE inhibitor lisinopril to preserve my kidney function, etc.). Luckily, my old and new plans do not require referrals for in-network specialists, so I rarely needed my PCP anymore, so my most recent visit was when I had a nasty case of bronchitis this past winter.

While I was reasonably happy with my endo, in recent years, his office has become kind of a factory, mostly due to the onslaught of newly diagnosed type 2 patients. In fact, the CDE's and nutritionists at the office started teaching "Introduction to Type 2 Diabetes" classes (as opposed to 1-on-1 teaching) to address the volume of patients who needed basic diabetes education. Not only has the practice added another endo (bringing the grand total to 5), quite frankly, they see far too many patients there, forcing me to have to schedule appointments at least 3 months in advance and the staff there is incredibly rude. To top that off, when I do see my endo these days, even though I've been a patient for 8 years, now I'm lucky to get maybe 20 minutes with the doctor. I saw the healthcare plan switch as an opportunity to make a change and was going to make the best of it.

My most pressing issue was the fact that I had another 2 refills on insulin, pen needles, lisinopril and perhaps most importantly test strips (I test on average about 14 times a day, which really isn't that extraordinary considering the ADA's recommendation is to test upon waking and going to bed, before and after each meal, anytime you get behind the wheel of an automobile -- which alone adds up to 10 times daily -- plus anytime I feel like I might be running a bit on the low side. Anyway, in spite of having several refills with Medco, the pharmacy benefits manager (PBM) for my old plan, since the switch, I had to get new scripts since my new plan used Caremark as their PBM. This put me in a bit of a quandry, since all of my scripts had been written by my endo, not my PCP. What was I supposed to do, visit my old endo and say "Hi, please write me a 90-day supply for a boatload of diabetes supplies, Oh, and by the way, since I you're no longer covered under my new plan, I'm being forced to fire you." Of course, that appointment would have to be paid for by me -- out-of-pocket, as my insurance no longer covers appointments with him!

Real awkward to say the least.

So I wrote a letter explaining the situation about my healthcare plan change to my PCP (who was covered as a preferred provider on both my old and new plan), as I would be running out of both insulin and testing supplies, not to mention most everything else because my refills could no longer be fulfilled. However, since my PCP had not written any scripts for me other than for an antibiotic and some cough medicine, they felt I should at least come in for an appointment, which I did. But I needed to move quickly as my diabetes supplies were running out, and my PCP had gone away on vacation, so I had to meet with another doctor in the practice. That doctor saw me agreed to write scripts for a 30 day supply with no refills. That was all I needed at the time, so I then sent the Rx to Caremark for fulfillment and waited.

And waited. And waited. And waited ...

After over 2 weeks, I finally picked up the phone and dialed Caremark's call-center hell, and collectively, was put on hold for a total of 1 hour 13 minutes and 47 seconds, and was also transferred repeatedly to many different people and/or departments, having to explain why I was calling (repeatedly) to each new person. After all of this, I finally learned that Caremark was holding the fulfillment of ALL of my prescriptions due to a question pertaining to a single item in the order. That would have been understandable if they contacted me to let me know what was going on, but they didn't -- I was forced to call. At issue was my order for insulin.

The doctor had apparently written the script in milliliters, but incorrectly expressed the quantity for some amount that would have been more insulin than I use in an entire year. They needed pre-authorization for an amount that large, but when I spoke to the pharmacist and explained the situation, I asked if the script was written for more than I actually needed, then asked why they couldn't fulfill an order for a (much) smaller quantity?

PBMs do this all the time, in fact, on some medicines, healthcare plans place limits on quantities they will pay for, so the PBMs will routinely fill only up to the quantity that will actually be paid for even if the script is written for more, so its not like they never do this. It's a standard business practice!

The representative then transferred me to what they said was the pharmacy department, who then told tried telling me that would be illegal, but when I challenged him by asking what law and under what jurisdiction, he then admitted that it was a Caremark "policy" not to do that. Caremark refused to bend on fulfilling a quantity of less than the script was written for, and I ultimately was referred to the "Presidents Office" (which is in reality, another high-priority phone queue). I then demanded that they fulfill the remainder of the order and I would take care of the insulin issue separately.

Here's where things got interesting.

I asked if Caremark could transfer the prescription to my local pharmacy, and they said they could. They had me instruct the pharmacist to call to facilitate the transfer. When I went to my local pharmacy, the pharmacist told me she called and was told by Caremark that the insulin prescription could not be transferred because it had a "hold" placed on it. I then called back and was FINALLY able to have the "hold" lifted and the script transferred to my local pharmacy. The pharmacist, having heard the whole story in person, said she could easily fulfill a quantity of less than the prescription was written for, although she didn't have Apidra insulin in stock, so I'd have to come back tomorrow and pick it up.

The long and short of this part of the story is that the pharmacist admitted to me that they have nothing but problems getting paid by Caremark since the company was acquired by CVS Corp., and that these kinds of issues were "the norm" with them. The good news is that my insulin needs had been addressed, and even though Caremark delayed fulfilling my order for nearly 3 weeks due to incompetence and organizational issues, my pharmacist was able to do it by fulfilling a 90 day supply but coding it as a 30 day supply, and because the script was written for far more, she had no ethical reservations about doing this on my behalf. Score 1 point for me for "tricking" Caremark into doing what they should have been able to do without my intervention.

Mail Order Screw Up

When my long-delayed mail order finally arrived, my the quantity of test strips was less than one-third of the quantity which was actually written on the doctor's prescription, so I again called Care-lessmark's call-center hell, and was again transferred numerous times to one incompetent person after another. This time, I was transferred 7 times, and collectively put on hold for a total of 1 hour, 43 minutes and 12 seconds. Let me just say that I did my homework in advance, checking with the healthcare plan to determine which brands were on the formulary, whether there were any quantity restrictions or doctor pre-authorizations required for the amount of test strips I would need, etc. I did far more than many consumers probably do, and everything checked out fine. So when my order arrived, I was confused. The quantity on the script was very clearly written for a 90-day supply, 14 boxes of 100 (actually, the quantity was 1,350 strips) One Touch Ultra test strips, and I verified that Empire would pay for those. What was Care-lessmark's problem? The apparent problem: the script did not specify how many times I (as the patient) needed to test each day. I then questioned Caremark, asking if they couldn't do simple division (e.g. a total 1,350 test strips divided by a 90 day supply equals 15 times per day). They then called the doctor (who I had never seen before that appointment, and likely will never see again) and said that Caremark needed to verify any quantity over the company's average of 4 test strips per day. The doctor responded not to the specific inquiry pertaining to MY order, by saying that under most circumstances, that amount seemed "reasonable" even though the prescription clearly stated 1,350 test strips.

The long story short is that I received an extra box after more fighting, which is collectively (with those already received) about enough for a 30 day supply, but that will run out and I'll have to deal with the headache of trying to order a new script for test strips sooner than 90 days, which is bound to mean more headaches to come. I have resigned myself to take CVS Caremark to small claims court because of the incredible stupidity of this whole issue, and to make sure that I get the last word on this issue. If they fail to show up in Queens County Small Claims Court (which they will likely not bother to even respond or send a representative), then the Court will rule in favor of the plaintiff (me). I really wish they weren't forcing me to do this!


Robert said...

Caremark frequently mails my prescriptions for insulin, test strips, blood pressure medicine, and glucagon to the wrong address. Then I have to go and get the order on my own time and money.

This past time they shipped me OneTouch basic strips instead of OneTouch ultra strips. I had to pay for them to mail me a new order of ultra strips (with a new prescription), and I'm still waiting for my refund on the basic strips that I sent back to them. Over a month and I still haven't gotten my $60 back, and even when I do it'll just be a Caremark store credit.

tmana said...

(1) When I was first diagnosed in 2002, and found out that my strips were supposed to be covered, my doctor stated that at that time, insurance would only cover 1 test per day for patients not on insulin, and only 4 tests per day for patients on insulin. At that time, Roche (Accu-Chek) was advocating an 8-10 test/day regimen for maintaining "tight control necessary to avoid developing complications of diabetes". Based on my co-pays at the time, I found it much cheaper to purchase my own strips. Only recently, under my current United Healthcare insurance, have unlimited tests been covered (and with zero co-pay!). When I find a new job with employer-subsidized health insurance, I suspect I may have to go back to paying my own way...
(2) I am a bit puzzled that you have issues with Caremark that you did not have with Medco, as they are both fronts for PBM RxHub. In either case, your customer service experience poses another layer of conccern regarding the recent merger of RxHub and SureScripts.
(3) Would you get any better service if you opted to fill your scripts through your most-local/most-convenient CVS store (now that there are CVS stores in the Five Boroughs and the suburbs)?

k2 said...

Absolutely un F-ING believable!
What a nightmare Scott!

I really hate insurance companies.
God forbid a patient like you,(like all of us!) who not only needs insulin on a daily basis to survive, but who obviously takes meticulous care of yourself AND has a chronic illness, should dare to test more than the "accepted" 4 times a day. What they think your going to do with all those strips? Smoke them ? Maybe sell them on the street for 10 bucks a vile - JESUS.

Do they not realize that as a diabetic, you:


If it comes down to court, KICK THEM IN THE ASS Scott, and please keep the folks in dBlogville posted.

All of us have your back!

Anonymous said...

I don’t suppose Small Claims Court addresses the issues of (lost) time you spent trying to compensate for an uncaring or incompetent corporate bureaucracy or mental anguish (will I actually get the supplies I need before I run out completely?) When you think about exploding healthcare costs, something that is NEVER added into the ‘grand total’ is the time (and aggravation) spent by patients trying to navigate a user-unfriendly corporate structure. If this could be quantified and converted to time = money, think how much higher healthcare costs would be!!!
Insurers are allowed to make life more difficult for patients with chronic illnesses . . . and patients have little or no recourse. If a patient’s very life depends on medicine/supplies, THAT patient is not in a take-it-or-leave-it posture. He/she truly is CAPTIVE to the insurance industry and BigPharma.
Personally, I import insulin. I’ve been diabetic for more than 50 years. I have needed insulin since day of diagnosis. My needs have not changed, yet the narrow pathway that FDA has provided so I can import natural insulin INCLUDES the requirement of a new prescription to accompany EACH ORDER. (I can only order a 6-month supply at one time.) Somehow, I see the medical profession has a finger in this pie . . . and are not without complicity in the difficulties forced upon our chronic disease population.


Scott K. Johnson said...

I'm sorry that you've had to go through all of that. It sucks, big time.

I think you have much more patience and determination than I have, and give you credit for doing all that you are doing and have done. Which is equally sucky because all you are trying to do is get your supplies! Ug.

It's not like you have anything better to do right? Like try to manage diabetes on top of everything else life throws at you!


Anonymous said...

You are not alone..... My husband has MS and needs his meds. It has been over a month and CareMark will not release the meds without the Dr.'s release of blood work. The Dr. will not release the bloodwork because it is in direct violation of HIPPA laws. His company is taking Caremarks side - We have been working on this everyday since day one. No one will budge and my husband is suffering!!! We now have to get an attorney to get the meds that he PAYS FOR out of every pay check but is being denied the benefit.