Community Chat

[newjersey]

@teainlondon, boy what a hassle for you.   Thanks for replying.

[newjersey]

@Q4u, 

[newjersey]

To all - I'm getting off here for now.  Gonna lay down.   Thank you for responding to me and when I find out what is going on, I will let you know.

[Noel7]

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@newjersey wrote:

@Noel7, thank you for replying.   That's what I was thinking too after I got the call - how can an insurance company tell someone how much medicine they can take???????  That's up to a doctor.    

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It seems to me it's like malpractice @newjersey

Good luck!

[Reba055]

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@newjersey wrote:

@Reba055, thank you for explaining this.    I'm still not TOTALLY understanding this because if a doctor says someone needs two pills or whatever amount of a medicine, how can an insurance company say no - that the patient can't have it?  I'm sorry - I am not very good at explaining myself.  

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@newjersey In fairness to the insurance company, I think it's to prevent stockpiling to pay only one month copay, for multiple months prescriptions. For instance, using the Proton pump inhibitors as example. If my copay were $15, my doctor could say I needed 3 a day or 90 pills when in fact I'm only taking 1 a day or 30 pills in one month. Instead of paying $15 for 90 pills, the insurance company is making sure you pay $15/month or $45  for 90 pills. Though this practice is not done much anymore by doctors because they are scrutinized, the good ole docs used to do that to help those in a fixed income or those struggling to make ends meet they can't really do that anymore. 

The problem arises when you actually need to take more. But that's why the doctor has to stick their neck out and get it approved to show you in fact need it. 

[FormerlyFabulous]

I frequently receive calls from CVS pharmacy. As a matter of fact, I received one this morning asking me if I wanted to have my regular medications put on a schedule so that I could pick them all up just once a month. A few weeks ago they asked me if I wanted my meds in a 90 day supply instead of 30. I have had problems with the communication between my doctor, the corp phamacy people who call to push the changes and my actual pharmacy. Seems like they are constantly evaluating their rxs...calling to tell you to pick up, putting you on auto refill etc.

[hyacinth003]

My prescription plan (Caremark-part of CVS) called my doctor to ask if my medication could be changed from 5mg twice a day to 10mg once a day.  I believe it is a cost saving issue.

It bugged me, because I had read it was better to have the split dosage than a single one.

But, I would just expect more of this as health care gets less personal. 

Hyacinth

[Perkup]

My SIL has had open heart surgery and is now on a med that his physician says he must have.  His insurance company, however,  said that they would like him on another heart med - similar, but not the same, and with a lower rating for his particular problem.  Talked with his surgeon who told the insurance company that if they denied him this med and he developed any problem, he would join my SIL in a lawsuit against them. 

They agreed to pay for the medication the doctor wanted.

[Marp]

@newjersey, I haven't yet read the responses to your post but yes this is happening.

My nephew has MS and the insurance company only wanted to allow one dose of a medication he has taken three times a day for a long time.

It was a battle but with his doctor's help he was able to get his entire prescription refilled.  That is the good news.  The bad news is when it comes to next month's refill they don't know if he will have to go through this again or be able to get the full prescription.  No one could answer that question for him.

[hyacinth003]

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@Mrsq2022 wrote:

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@newjersey wrote:

@Reba055, thank you for explaining this.    I'm still not TOTALLY understanding this because if a doctor says someone needs two pills or whatever amount of a medicine, how can an insurance company say no - that the patient can't have it?  I'm sorry - I am not very good at explaining myself.  

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That's not quite it...you can have the medicine your doctor prescribed.  The pharmacy will fill this for you and you can certainly take the dose your doctor has prescribed.  

The insurance company isn't stopping that from happening.  They just don't want to pay for the amount you are prescribed and will only pay for half the dose.  That is a big difference from you not being provided the doseage of medication that you've been prescribed.  If the pharmacy refused to fill it at the high doseage, that would be a different issue.

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Right, follow the money!  The pharmacy can provide you with any dose the doctor wants (if it is safe), but your insurance company doesn't have to pay for it all.  They ca n pay for 60 days, 90 days, 30 days, whatever the policy says.

Follow the money.  When someone else pays, they can make rules.

Hyacinth