My office has been very displeased with our new insurance company. This change in insurance is going to cost me at least $4,000 for medications. I will share my story so you can avoid the same problems.
One my wife's medications is Latuda (no generic alternative). She has been on a dosage of 2 pills a day for 1.5 years. CareFirst covered her prescriptions with no problems. We are now on UnitedHealthCare and they will pay for only 1 pill a day. I didn't realize that this was costing me $1,000/month until January. This is partly because the facility was ordering the Latuda from the pharmacy they work with because OptumRX, UHC's pharmacy, wouldn't fill the prescription. For some reason the pharmacy didn't put the Latuda for Oct and Nov to insurance until January, so I didn't see the $2,500 bill for December until late January. I had been aware in November that there was an issue and I was trying to get appeals in to the insurance company but they kept giving out the wrong fax number.
Yesterday I received the results of the appeal. It was denied. The policy will only pay for 1 pill a day and if my wife needs more I have to pay for it. It was a form letter, you could tell by the use of "prescription(s)", as if they didn't know if it was one or more prescriptions involved.
So, this is what I was supposed to do, and I am sure this will apply to other insurance policies. Any time I get a prescription I am to go to the insurance web site and see if it is covered, including checking the quantity that will be covered. Now, if we only use the UHC mail order pharmacy anything not covered will not be shipped. If I walk into a pharmacy I would have been stopped due to insurance not covering. But a pharmacy that is filling an order for a facility has to fill the prescription whether or not insurance covers it.
I printed out all prescription claims since Oct 1. I see that they did pay for Latuda for 1 pill a day for months Oct through Jan. Fortunately staff had already reduced her Latuda dose in January because she was appearing sedated to 1.5 pills a day, and they are now reducing the prescription to 1 pill a day to meet the insurance decision and because she has responded well to the Latuda reduction. So I am optimistic that my wife will do well with 1 pill a day and this will not be an ongoing drain on finances.
And the story changes once again. But in my favor this time.
I talked with someone at the pharmacy. She reviewed my case. Said that for 4 months Insurance said they would pay for only 30 of her 60 pills for one prescription. But insurance ended up for paying the entire bill. I ask no questions. This was very unexpected.