7 ms·

I have United Healthcare, and I have to say I've seen this happen to me as well. I'm on a long term maintenance medication, which is delivered by patch. I was

by cbanek 9y ago

I have United Healthcare, and I have to say I've seen this happen to me as well. I'm on a long term maintenance medication, which is delivered by patch. I was on the generic in my previous health plan, so my new doctor prescribed the same generic. I used the mail order pharmacy and they told me that a 90 day supply would cost $347. I asked why it was so much, and where my prescription benefits came in. They said they didn't cover the generic, and I said well do you cover the name brand one? They said they did, but they couldn't give it to me because my doctor had ordered the generic. If I ordered the name brand, it would be $100 for a 90 day supply, which is a huge difference. I called my doctor, and got them to change the prescription. None of the people at United Healthcare were offering any of this information, and I basically had to pry it out of them to figure out why they were trying to gouge me. Also, this was their own private mail order pharmacy, so all the money was going to them as well. Ask a lot of questions before paying a lot of money.

pcurve 9y ago
"They said they didn't cover the generic, and I said well do you cover the name brand one? They said they did, but they couldn't give it to me because my doctor had ordered the generic. If I ordered the name brand, it would be $100 for a 90 day supply, which is a huge difference." 3 possibilities: 1. Your doctor wrote "dispense as written" on the script, which barred United from substituting. This is highly unlikely because doctors only do this when prescribing name brand. 2. United didn't have system rules in place to flag this type of thing because there's no financial incentive to do so for United or your employer who is actually paying for your drug. Chances are, if generic costs $347, then brand name costs more. When you pay $100, your employer is still paying the remaining, which could be $250+ When you get generic, your employer pays nothing. 3. United didn't have system rules in place to flag this because they are just incompetent. The fact that they don't cover generic means that your employer is getting rebate from brand. Unless your employer is trying to save a few bucks by intentionally screwing over their employee, United system should've flagged this an simply auto substituted to cheaper alternative. Either way, unless brand was materially different, United is within legal right to auto substitute without needing a new scripts. In short, they served you a bunch of turd sandwiches.
- cbanek 9y ago
  I'm actually self employed, and I got this health care policy on the health care exchanges - there's no employer in the picture, which is probably why they're trying to shift the cost to me, as opposed to paying for the brand. So really, without an employer, it's just because there's no financial incentive for them to do so. Actually, it's negative incentive for them, because they tried to get me to pay for something they wouldn't have to pay anything for. Then for dispensing it, they charge me since they are also the pharmacy.
  - pcurve 9y ago
    Yes, without employer in picture, what they did was probably deliberate. They also straight up lied to you about needing a new script. I work in the industry and familiar with some of these practices, but this is pretty low.
  - drewmol 9y ago
    I understand if you don't want to answer this, but is there a subsity covering part of your plan you purchased through healtcare.gov?
    - cbanek 9y ago
      No, I pay the full price myself out of pocket (and write it off on my taxes).
      - drewmol 9y ago
        Thx for the response, wondering what UHG's potential motivations may be. I used to work in the medical billing industry, and UHG had a very poor reputation (among major insurers) with the two healthcare management consultants I worked closely with. (edit: UHC-->UHG)
        mannykannot 9y ago
        The last paragraph in the article gets to the point: “There’s only one reason why they’re requiring you to use a more expensive product,” Mr. Frankil said. “Because somewhere down the road, somebody is earning more money.” The brand-name maker would like the generic market to dry up, so it may be as simple as the brand-name maker selling its product at a reduced price on condition that the insurer cuts off the generics. Given that some patients demand brand-name drugs and some doctors acquiesce, this may be cheaper for the insurer. My doctor has a straightforward attitude - referring to patients who demand brand-name drugs "I told them 'I take generics. My kids take generics. If you won't take generics, find another doctor!'" (that was before the practice described here emerged. I am sure he has something to say about it...)
secabeen 9y ago
I had a similar situation with my mail order pharmacy. Ordered a 90-day supply of maintenance medication, was charged brand rates against my deductible. They dispensed the brand rather than the generic. Asked why, they said, well, we have a deal with the company, you get brand drugs at the cost of the generic co-pay! They neglected to understand that some of us don't have co-pays for Rx, and pay the actual cost. Solution? Go to Costco, get 30-day subscription, pay pennies per pill.
gambiting 9y ago
This might be a stupid question, since I don't know how the US system works - if you have health insurance, why do you have to pay anything for drugs "covered" by your insurer? If they cover a medication, why is there anything left to be paid by you? Do you also have to pay if you have any treatment that is "covered" by your insurer?
- adventured 9y ago
  Health insurance plans have varying coverage for drugs (and those plans can vary a lot state to state), so that's going to depend on the plan. Decent plans typically pay everything but a very small charge. Average plans often have limits to routine prescription drug coverage in a given year. A medication I took last year cost around $90-$100 or so. The insurance covered all but $10 of that.
  - lawnchair_larry 9y ago
    Many have large deductibles as well, so it's common for yearly medication costs to be out of pocket.
- Amezarak 9y ago
  As an example, I have a 4500 dollar deductible. That means until I pay 4500 for prescriptions, doctor visits, labs, ER visits, etc., insurance pays nothing, though I do get their negotiated "discount" from the provider. After that, the insurance pays 80% of the cost until I have paid out some even larger number, at which time they pay 100% until January rolls around. This is a pretty normal plan, and the type the guy you're responding to is describing; older plans often have much lower deductibles and have copays, though premiums tend to be higher, but one they're hard to find now. It's very easy to meet a 4500 deductible. I've already done it for the year without any major health events.
  - akuji1993 9y ago
    For anyone in Europe in a normal healthcare plan, US healthcare is just a fucking joke.
lojack 9y ago
Just because it's their own private pharmacy doesn't necessarily mean they follow a different set of rules. The PBM probably has that pharmacy set up like any other and treat it as a preferred pharmacy with internally negotiated discounts.
joshstrange 9y ago
BriovaRx I assume? These guys are the worst. OptumRx (might be who you have through United as well) screwed me over because no one ever explained to me what the hell a "specialized" medication was. I was put on a $drug and so when asked where I wanted to fill it I told my doctor to send it to my local Kroger Pharmacy. I went and tried to use my insurance but it wouldn't run for this $drug. I called OptumRx (the number on my healthcare card) and they said it should work. I gave them all my info, they assured me Kroger Pharmacy was In-Network, and they had me stand in line again so that they could talk to the pharmacist. No one could figure out what was wrong so the pharmacist gave me 3 pills to get started and OptumRx told me it would be cleared up by tomorrow and they would call me. Day 1, no call. Day 2, no call. Day 3 I call the pharmacy and they say they haven't heard anything from OptumRx, I called OptumRx and they finally realized that this $drug is a special drug that can ONLY be filled by their online pharmacy BriovaRx. I get transferred to BriovaRx and they say they can mail me the drug in 2-3 days and I tell them that's not going to work because I took my last pill today and there aren't supposed to be any breaks in the medication. Finally they cave and call in an "override" so I can get it from Kroger this one time. They also fucked up a delivery once and told me they couldn't send more pills until they figured out what happened to the last package (which could take days) and I was 1 pill away from being out. I had to fight my way through people telling me there is nothing that could be done about it until finally, again, someone called in an override. Mail order may be nice and all but when I can't re-order until I'm less than a week out and shipping doesn't always work as expected it's a huge PITA and a big stressor. I order EVERYTHING off Amazon so trust me when I say I prefer the idea of mail order but when I need a medication I want to be able to walk down to the Kroger Pharmacy and fill it instead of waiting for something that might not come on time.
- compuguy 9y ago
  Express Scripts is pretty bad as well. I've lost count of how many hours I've spent on having to jump through the oddies of mail order pharmacies...
  - baldfat 9y ago
    Well you saved me. I was going to do a 90 day med with them to save a trip to the pharmacy.

by cbanek 9y ago

pcurve 9y ago

"They said they didn't cover the generic, and I said well do you cover the name brand one? They said they did, but they couldn't give it to me because my doctor had ordered the generic. If I ordered the name brand, it would be $100 for a 90 day supply, which is a huge difference." 3 possibilities: 1. Your doctor wrote "dispense as written" on the script, which barred United from substituting. This is highly unlikely because doctors only do this when prescribing name brand. 2. United didn't have system rules in place to flag this type of thing because there's no financial incentive to do so for United or your employer who is actually paying for your drug. Chances are, if generic costs $347, then brand name costs more. When you pay $100, your employer is still paying the remaining, which could be $250+ When you get generic, your employer pays nothing. 3. United didn't have system rules in place to flag this because they are just incompetent. The fact that they don't cover generic means that your employer is getting rebate from brand. Unless your employer is trying to save a few bucks by intentionally screwing over their employee, United system should've flagged this an simply auto substituted to cheaper alternative. Either way, unless brand was materially different, United is within legal right to auto substitute without needing a new scripts. In short, they served you a bunch of turd sandwiches.

cbanek 9y ago
I'm actually self employed, and I got this health care policy on the health care exchanges - there's no employer in the picture, which is probably why they're trying to shift the cost to me, as opposed to paying for the brand. So really, without an employer, it's just because there's no financial incentive for them to do so. Actually, it's negative incentive for them, because they tried to get me to pay for something they wouldn't have to pay anything for. Then for dispensing it, they charge me since they are also the pharmacy.
- pcurve 9y ago
  Yes, without employer in picture, what they did was probably deliberate. They also straight up lied to you about needing a new script. I work in the industry and familiar with some of these practices, but this is pretty low.
- drewmol 9y ago
  I understand if you don't want to answer this, but is there a subsity covering part of your plan you purchased through healtcare.gov?
  - cbanek 9y ago
    No, I pay the full price myself out of pocket (and write it off on my taxes).
    - drewmol 9y ago
      Thx for the response, wondering what UHG's potential motivations may be. I used to work in the medical billing industry, and UHG had a very poor reputation (among major insurers) with the two healthcare management consultants I worked closely with. (edit: UHC-->UHG)
      - mannykannot 9y ago
        The last paragraph in the article gets to the point: “There’s only one reason why they’re requiring you to use a more expensive product,” Mr. Frankil said. “Because somewhere down the road, somebody is earning more money.” The brand-name maker would like the generic market to dry up, so it may be as simple as the brand-name maker selling its product at a reduced price on condition that the insurer cuts off the generics. Given that some patients demand brand-name drugs and some doctors acquiesce, this may be cheaper for the insurer. My doctor has a straightforward attitude - referring to patients who demand brand-name drugs "I told them 'I take generics. My kids take generics. If you won't take generics, find another doctor!'" (that was before the practice described here emerged. I am sure he has something to say about it...)

secabeen 9y ago

I had a similar situation with my mail order pharmacy. Ordered a 90-day supply of maintenance medication, was charged brand rates against my deductible. They dispensed the brand rather than the generic. Asked why, they said, well, we have a deal with the company, you get brand drugs at the cost of the generic co-pay! They neglected to understand that some of us don't have co-pays for Rx, and pay the actual cost. Solution? Go to Costco, get 30-day subscription, pay pennies per pill.

gambiting 9y ago

This might be a stupid question, since I don't know how the US system works - if you have health insurance, why do you have to pay anything for drugs "covered" by your insurer? If they cover a medication, why is there anything left to be paid by you? Do you also have to pay if you have any treatment that is "covered" by your insurer?

adventured 9y ago
Health insurance plans have varying coverage for drugs (and those plans can vary a lot state to state), so that's going to depend on the plan. Decent plans typically pay everything but a very small charge. Average plans often have limits to routine prescription drug coverage in a given year. A medication I took last year cost around $90-$100 or so. The insurance covered all but $10 of that.
- lawnchair_larry 9y ago
  Many have large deductibles as well, so it's common for yearly medication costs to be out of pocket.
Amezarak 9y ago
As an example, I have a 4500 dollar deductible. That means until I pay 4500 for prescriptions, doctor visits, labs, ER visits, etc., insurance pays nothing, though I do get their negotiated "discount" from the provider. After that, the insurance pays 80% of the cost until I have paid out some even larger number, at which time they pay 100% until January rolls around. This is a pretty normal plan, and the type the guy you're responding to is describing; older plans often have much lower deductibles and have copays, though premiums tend to be higher, but one they're hard to find now. It's very easy to meet a 4500 deductible. I've already done it for the year without any major health events.
- akuji1993 9y ago
  For anyone in Europe in a normal healthcare plan, US healthcare is just a fucking joke.

lojack 9y ago

Just because it's their own private pharmacy doesn't necessarily mean they follow a different set of rules. The PBM probably has that pharmacy set up like any other and treat it as a preferred pharmacy with internally negotiated discounts.

joshstrange 9y ago

BriovaRx I assume? These guys are the worst. OptumRx (might be who you have through United as well) screwed me over because no one ever explained to me what the hell a "specialized" medication was. I was put on a $drug and so when asked where I wanted to fill it I told my doctor to send it to my local Kroger Pharmacy. I went and tried to use my insurance but it wouldn't run for this $drug. I called OptumRx (the number on my healthcare card) and they said it should work. I gave them all my info, they assured me Kroger Pharmacy was In-Network, and they had me stand in line again so that they could talk to the pharmacist. No one could figure out what was wrong so the pharmacist gave me 3 pills to get started and OptumRx told me it would be cleared up by tomorrow and they would call me. Day 1, no call. Day 2, no call. Day 3 I call the pharmacy and they say they haven't heard anything from OptumRx, I called OptumRx and they finally realized that this $drug is a special drug that can ONLY be filled by their online pharmacy BriovaRx. I get transferred to BriovaRx and they say they can mail me the drug in 2-3 days and I tell them that's not going to work because I took my last pill today and there aren't supposed to be any breaks in the medication. Finally they cave and call in an "override" so I can get it from Kroger this one time. They also fucked up a delivery once and told me they couldn't send more pills until they figured out what happened to the last package (which could take days) and I was 1 pill away from being out. I had to fight my way through people telling me there is nothing that could be done about it until finally, again, someone called in an override. Mail order may be nice and all but when I can't re-order until I'm less than a week out and shipping doesn't always work as expected it's a huge PITA and a big stressor. I order EVERYTHING off Amazon so trust me when I say I prefer the idea of mail order but when I need a medication I want to be able to walk down to the Kroger Pharmacy and fill it instead of waiting for something that might not come on time.

compuguy 9y ago
Express Scripts is pretty bad as well. I've lost count of how many hours I've spent on having to jump through the oddies of mail order pharmacies...
- baldfat 9y ago
  Well you saved me. I was going to do a 90 day med with them to save a trip to the pharmacy.