What are my options for my insurance?

What options do I have if my Insurance Company denies coverage of a prescription?

• I work for a very large retail chain that until this week never had any problems with my insurance benefits. Blue Cross Blue Shield is my health insurance and my company has arranged for Medco to handle all the prescription/pharmacy insurance and claims for 2011. For the last 4 years I have been on generic Adderral (D-Amphetamine Salt Combo) 10 mg, for my adult ADHD. Every month my Doctor writes me a prescription and I take it to my local pharmacy and my insurance pays its part and I pay $4 under the generic prescription program, until this month January 2011 when my Insurance company changed to having Medco handle my prescription insurance and claims. I dropped off my prescription for my Adderral on Jan. 14th, 2011, 1 day before I was going to run out. My pharmacy calls me later that evening and informs me that my insurance is denying payment on the medication and needs pre-authorization from my Doctor's office. So I said okay and thought it was weird. So for 2 days I had to wait until the Pharmacy could get a hold of my Doctor's office (had to wait until Monday) before they could have them fill out the pre-authorization form to fax to my insurance company in hopes Medco would approve the claim and pay on my prescription. Medco denied coverage for my prescription (note: I have been taking this same medication for 4 years without any problems from any other insurance). So I call Medco on Tuesday and they tell me that it was denied due to "formulary changes in the drug that could have negative effects on a underlying condition," I ask them what does this mean and they inform me I should call my Doctors office and see if they perhaps sent information saying anything about hypertension, etc. I called my Doctors office and they said they did not say anything about hypertension, and even if they did it should not matter due to the fact they have seen me and would not prescribe me medication for the last 4 years if it was going to have a chance at hurting me. So I called Medco back and told them this and they said I could write an appeal but that could take up to 15 days or I could pay full retail amount for the prescription ($135) and write an appeal and if it gets approved I could get reimbursed. I informed them that this was now the 4th day without my medication and that living with ADHD is hard enough, so they then transfered me to a Pharmacists they had on staff so he could tell me the importance of not getting off my medication. I told him I never expected to have my prescription denied and that it is their fault I have been off it 4 days, and all he could say is you need to get back on it. So I talked to customer service again and they could not give me any details as to why they denied coverage and for the last 4 years it has been approved. I am at wits end, what should I do? How do I go about writing an appeal to them? I can even prove for the last 4 years I have been on this medication. Someone please help. I googled "Medco" and actually found other people having problems like me, but their troubles never received any solutions. SOMEONE PLEASE HELP!!! I can not afford to pay $135 a month for medicine that I know I am supposed to be getting for $4/month.

• Answer:

  ~~First off to the other answerer, OBAMA CARE does not exists. If you are referring to health care reform changes, wrong again. They are not in effect yet, so please give correct information when you answer a question, and when you don't understand something, better not to answer than to give false information. For this problem, I think whoever explained this to you from the insurance company must have relayed the information incorrectly. You can not write anything as you are not a doctor and your letter would have no bearings on changing this. What has to happen is to speak with your doctor or his/her nurse first thing in the morning. The justification has to come from the prescribing provider. No insurance can just deny a needed medication. If they say Adderal is not formulary for them, them some equivalent generic has to be offered. So have the providers office call your insurance company and argue this out. If they have no formulary then they must give you the brand name. Medical providers have to justify medications all the time, it's part of the process insurance companies make them waste their time on. So stand firm and tell your provider or the nurse to get this taken care of tomorrow so you can get back on your prescribed medication. They should not be having you deal with this at all. If they give you trouble, then find another doctor, all providers know this has to be done, it's a part of business. So they need to provide this service to take care of you, their patient. Also check with them and see if they have samples on hand to give you until this is straightened out. If they do their job correctly, you should have your medication tomorrow. It's ridiculous what you have been put through. Insurance companies have no mercy! When the reform changes in 2014 is in place, at least this type of worry will be eliminated.~~