4 ms·

"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

by 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...)
        saalweachter 9y ago
        I wonder if this is an end-run around my hands-down favorite part of the ACA, the hard limit on the "Medical Loss Ratio" (MLR). Insurance companies must spend at least ~80% (the number varies by plan type, but call it 80%) of premiums on medical expenses, and if they don't, that's when you get those refund checks in the mail. (In the 90's, you had a few insurance plans with >90% MLRs, but by the early 2000's the average had declined to 70%, and you had some companies selling plans to college kids with a 10% MLR.) This is overall good, because insurance is one of the few industries that benefits from monopoly conditions (bigger risk pools are better), so you want a hard cap on how much money the monopolies can extract. But maybe demanding non-generics is a way to increase "medical losses", which in turn is a way to increase their permissible profits?
tbrownaw 9y ago
United didn't have system rules in place to flag this because they are just incompetent. I could definitely see some junior dev writing "if (isNameBrand()) { lookForGenerics(); }", even if the requirements doc was less specific and just said "look for lower-cost alternatives". Catching that sort of extraneous assumption is one of the things that comes with experience.
lojack 9y ago
I actually think the first possibility is more likely than you think. OP said he was previously using a generic patch. Patches can have different dosing instructions, and when switching between generics and name brand the doctor may want to give additional instruction. They may have written DAW to try to continue the same therapy without additional instruction. Usually not a problem, but OP switched plans. The fact that they wouldn't dispense an alternative when asked until having the doctor update the Rx kind of supports this as well.
- cbanek 9y ago
  It's she actually. And the patches are equivalent in terms of dosage, and I've been on both. They even look exactly the same. The only thing that might be different, as far as I can tell, is the adhesive they use for the sticky part.
  - lojack 9y ago
    Apologies for making the assumption :-) It's possible there are different alternatives that have different dosages. If you really wanted to find out though, you could always ask your doctor. Dispense as written can be used because the doctor gets kickbacks, but there are frequently more innocent reasons for it. Perhaps the adhesive isn't as effective, but ultimately there are any number of things that can differentiate generics from brand names or other generics. Pills tend to be more similar, but even then there can be differences despite technically being the same drug.
skywhopper 9y ago
I have United Healthcare and when I first switched to theme I was informed by my pharmacy that UHC requires one of my prescriptions to be written to require name-brand-only before they can fill it. This often leads to problems filling it because of supply, and the copay is 3x higher, and if the doctors office makes a mistake I have to go back to them to correct it (it's for Adderall, so the pharmacy and doctor cannot exchange the prescription over the phone or computer--I have to do all the back and forth in person with paper). This is, obviously, quite irritating, not to mention expensive.
- tssva 9y ago
  I have UHC and take Adderall XR. I have never had an issue because of how the prescription was written. My doctor has always written it for Adderall XR with generic substitution allowed. This allowed me to get the generic version prior to switching to UHC and has allowed me to get the name brand without issue after switching to UHC. Even if the way your doctor sometimes writes the prescription causes an issue. It seems this is easily preventable with minimal effort on your part. Just remind your doctor how it needs to be prescribed and double check the prescription before leaving the office. My co-pay for Adderall XR with UHC is the same as my co-pay previously for the generic version. Maybe I was getting gouged before.
- u801e 9y ago
  > it's for Adderall, so the pharmacy and doctor cannot exchange the prescription over the phone or computer--I have to do all the back and forth in person with paper This is somewhat off-topic, but I've always thought that the requirement for using a paper prescription for controlled substances was counter-intuitive. To me, it would make more sense to do this electronically and not involve the patient at all in the transfer of the prescription itself. Plus, the electronic system should be able to verify the identity of the prescribing physician and dispensing pharmacist to both parties involved as well as a central authority if necessary, which is more difficult to do with a paper prescription.
  - bspn 9y ago
    >This is somewhat off-topic, but I've always thought that the requirement for using a paper prescription for controlled substances was counter-intuitive Is this a state-specific requirement? My wife is on a few controlled substances and we never receive paper scripts, but instead her doctor sends it in electronically and the pharmacy calls us when it's ready.

by pcurve 9y ago

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...)
      - saalweachter 9y ago
        I wonder if this is an end-run around my hands-down favorite part of the ACA, the hard limit on the "Medical Loss Ratio" (MLR). Insurance companies must spend at least ~80% (the number varies by plan type, but call it 80%) of premiums on medical expenses, and if they don't, that's when you get those refund checks in the mail. (In the 90's, you had a few insurance plans with >90% MLRs, but by the early 2000's the average had declined to 70%, and you had some companies selling plans to college kids with a 10% MLR.) This is overall good, because insurance is one of the few industries that benefits from monopoly conditions (bigger risk pools are better), so you want a hard cap on how much money the monopolies can extract. But maybe demanding non-generics is a way to increase "medical losses", which in turn is a way to increase their permissible profits?

tbrownaw 9y ago

United didn't have system rules in place to flag this because they are just incompetent. I could definitely see some junior dev writing "if (isNameBrand()) { lookForGenerics(); }", even if the requirements doc was less specific and just said "look for lower-cost alternatives". Catching that sort of extraneous assumption is one of the things that comes with experience.

lojack 9y ago

I actually think the first possibility is more likely than you think. OP said he was previously using a generic patch. Patches can have different dosing instructions, and when switching between generics and name brand the doctor may want to give additional instruction. They may have written DAW to try to continue the same therapy without additional instruction. Usually not a problem, but OP switched plans. The fact that they wouldn't dispense an alternative when asked until having the doctor update the Rx kind of supports this as well.

cbanek 9y ago
It's she actually. And the patches are equivalent in terms of dosage, and I've been on both. They even look exactly the same. The only thing that might be different, as far as I can tell, is the adhesive they use for the sticky part.
- lojack 9y ago
  Apologies for making the assumption :-) It's possible there are different alternatives that have different dosages. If you really wanted to find out though, you could always ask your doctor. Dispense as written can be used because the doctor gets kickbacks, but there are frequently more innocent reasons for it. Perhaps the adhesive isn't as effective, but ultimately there are any number of things that can differentiate generics from brand names or other generics. Pills tend to be more similar, but even then there can be differences despite technically being the same drug.

skywhopper 9y ago

I have United Healthcare and when I first switched to theme I was informed by my pharmacy that UHC requires one of my prescriptions to be written to require name-brand-only before they can fill it. This often leads to problems filling it because of supply, and the copay is 3x higher, and if the doctors office makes a mistake I have to go back to them to correct it (it's for Adderall, so the pharmacy and doctor cannot exchange the prescription over the phone or computer--I have to do all the back and forth in person with paper). This is, obviously, quite irritating, not to mention expensive.

tssva 9y ago
I have UHC and take Adderall XR. I have never had an issue because of how the prescription was written. My doctor has always written it for Adderall XR with generic substitution allowed. This allowed me to get the generic version prior to switching to UHC and has allowed me to get the name brand without issue after switching to UHC. Even if the way your doctor sometimes writes the prescription causes an issue. It seems this is easily preventable with minimal effort on your part. Just remind your doctor how it needs to be prescribed and double check the prescription before leaving the office. My co-pay for Adderall XR with UHC is the same as my co-pay previously for the generic version. Maybe I was getting gouged before.
u801e 9y ago
> it's for Adderall, so the pharmacy and doctor cannot exchange the prescription over the phone or computer--I have to do all the back and forth in person with paper This is somewhat off-topic, but I've always thought that the requirement for using a paper prescription for controlled substances was counter-intuitive. To me, it would make more sense to do this electronically and not involve the patient at all in the transfer of the prescription itself. Plus, the electronic system should be able to verify the identity of the prescribing physician and dispensing pharmacist to both parties involved as well as a central authority if necessary, which is more difficult to do with a paper prescription.
- bspn 9y ago
  >This is somewhat off-topic, but I've always thought that the requirement for using a paper prescription for controlled substances was counter-intuitive Is this a state-specific requirement? My wife is on a few controlled substances and we never receive paper scripts, but instead her doctor sends it in electronically and the pharmacy calls us when it's ready.