Eliza Grace was born on March 15, 2006, at 26 weeks, 4 days, weighing 1 pound 4 ounces and measuring just 11.5 inches long. She is the light of my soul and this is the story of our life in the big city.

Tuesday, February 24, 2009

United Health Care and Oxford Health Plans...

... should be ashamed of themselves.

After much "hondling" with United Health Care/Oxford Health Plans they finally decided to suck it up and do what they should have long ago done and pay for Eliza's formula since it is her sole source of nutrition (as an aside this would NEVER had been an issue if the formula was consumed via a tube instead of orally).

On February 4, 2009 UHC/OXHP precertified both Eliza's formula and calorie supplement. WooHoo, such a nice birthday present for me. So I do what I am told to do by UHC/OXHP and call Medco, their pharmacy provider, to arrange for delivery. After 10 (TEN) hours of calls where I am alternatively told that Medco will direct ship the products and then that they won't ship the products, it is finally determined I need to find a retail pharmacy in my area to "fill" the precertified prescriptions. I am given a list of 26 pharmacies to call, and call I do. Not one of the 26 carries these products since, as one neighborhood pharmacist told me, "there is no profit in carrying products that have such a low demand." These are not standard shelf items.

I call the good folks at Nestle to see if they know of a pharmacy that carries these two products. Nestle claims they have no such list. I find this a bit hard to believe and suspect they much prefer me to continue to buy the stuff straight from them at a hefty profit. Nestle also advises they will not bill UHC/OXHP or Medco directly.

So I sally-forth to the online pharmacies and EUREKA! CVS.com is more than happy to fill the prescriptions! Life is grand, I make room in my small apartment for the cases of nectar that I am anticipating will arrive any day.

Then I get the email from CVS.com stating (are you ready) that UHC/OXHP/Medco have denied the claim since although they are precertified these products are not covered under my pharmacy benefit. Huh? If it is not covered under my "pharmacy" benefit, then one would wonder why Medco was involved at all, since Medco ONLY deals with "pharmacy" benefits and it was Medco that gave me the names of the 26 pharmacies to call.

So I once again dial the UHC/OXHP/Medco 800 number. By now I have spent in excess of 35 (THIRTY-FIVE) hours trying to get the products that UHC/OXHP has precertified. Four hours and three calls later I am told that these products are covered as a "medical" benefit and I need to go to a medical supply company. While I am clearly vexed at the waste of time, I am thrilled to place that call to Apria for the products. I am in luck! Apria carries them and they can be at my door in a jiffy!

Guess what happens next?

UHC/OXHP DENIES the claim from Apria. Why you ask? Because the products are NOT covered as medical benefits but rather are pharmacy benefits. Huh? No dear readers you are not confused nor is your reading comprehension failing you.

So to sum up:

February 4, 2009: the products are pharmacy benefits

February 10,2009: the products are medical benefits

February 23, 2009: the products are pharmacy benefits.

As of today "Jim" a supervisor was "looking into this" since he "felt" this was a pharmacy benefit. Since "Jim" managed to disconnect me after 97 minutes on hold today I am not hopeful that "Jim" has any idea what he is doing any more so than "Tammy," "Sharon," "Lucille," "Jennifer," "Arlene," "Suzanne, "Ronald" or "May" knew in my earlier calls.

I have now spent a full work week trying to simply obtain the products which United Health Care/Oxford has already approved. This is in addition to about 100 hours of my time trying to get the stuff covered in the first place.

This is just wrong and is a simple example of what is so very broken with our health care system. Caring for a special needs child and working full time is hard enough, do these people take some perverse joy in making this even more difficult? I think they do. I am sure UHC/OXHP dearly wishes Eliza was not one of their insureds. Surely they could have used the $2.7 million they have already spent on Eliza for a few swanky corporate outings.

To spite UHC/OXHP I will NOT move our company's group policy to another carrier but rather will make sure that every dime is sucked out of this wretched company. I will happily use my insomnia to their detriment and make their corporate "life" as miserable as I possibly can. Yes indeed.

9 comments:

MamáChanga said...

Oh Anne! All I can say after reading that wretched account is Ugghh!! (Well, that's all I can type because all the rest are expletives). I'll pray that this gets resolved soon.

Hugs & Blessings!

Sarah said...

Oy vey, for crying out loud. I would love to say that a G-tube would make life easier - um, NOT. Insurance companies suck, period. I curse everyone who has ever denied a claim in insurance to be struck with the very disease and/or condition they have denied.

Natalie and Abigail said...

Good grief. When I first started reading I thought, "yea! You're rich now!" I was thinking of all the zillions of dollars you'll save each month. Now, I'm sad again:-(

Insurance companies are so stupid. It really just boggles the mind. I mean, isn't there SOMEONE in charge who can just make a decision, declare it so, and then it is?

I hope that tomorrow they figure out which it is and the nector of the gods shows up on your doorstep.

Anonymous said...

Maybe you tried this, but just in case... One of the approved pharmacies that doesn't CARRY the product can still (if they are so inclined) SPECIAL ORDER it for you. They just have to find the product number and punch it in to the next day's order. (Finding the appropriate product number for a Boost product isn't so easy since there are so many of them, but if you have the UPC/NDC# errors should be reduced.) At my pharmacy we special order products almost every day: everything from rare toothpastes to special sunscreens. Try calling back a few of the less rude and more convenient pharmacies and ask if they can special order a product for you. The next, and probably harder, step will be the billing. The pharmacy will most likely not have a clue as to how to bill it, as formulas are usually paid for thru medical supply companies and not thru pharmacies. Maybe you can get a receipt and submit it to UHC/Oxford for reimbursement?

I have UHC and they pay for the Boost Kid Essentials 1.5 with Fiber for po use thru Apria, but UHC works very differently depending on which plan the employer has. Dealing with insurance companies is a major pain in the behind. At least when one does it as a pharmacist one gets paid for it! Seriously, being on the phone with insurance companies can be what one does over 50% of one's working hours.

Good luck! I am sure you will figure out everyone's bureaucratic requirements eventually if you just stick with it (and if you always ask to talk to the phone person's manager and then the next higher manager when someone is just not getting it)!

LT

Anne, Eliza Grace's mom said...

LT wrote:

Maybe you tried this, but just in case... One of the approved pharmacies that doesn't CARRY the product can still (if they are so inclined) SPECIAL ORDER it for you. They just have to find the product number and punch it in to the next day's order. (Finding the appropriate product number for a Boost product isn't so easy since there are so many of them, but if you have the UPC/NDC# errors should be reduced.)



Thanks LT! A few very nice pharmacists at the chain pharmacies suggested the same thing and suggested that if I knew a local pharmacy they could order it for me.

The really sad part of this entire process has been that I DO know a local pharmacist who has been my familiy's pharamacist for 20 years. I gave him the NDC code and his repsonse was "well there's really not much profit in this for a small guy like me to special order it." Nice huh?

So I added up how much money out of pocket in copays and over the counter things for the past three years I have paid this fellow. Most of our meds seem to have the $50 or $25 copay and my IVF meds were not covered at all. I stopped adding when I hit $10,000 and that doesn't even count the profit he made on the prescription itself.


But there is light at the end of the tunnel...

Anne, Eliza Grace's mom said...

UPDATE...

"Jim" the UHC/OXHP supervisor has finally decided that under the Oxford Freedom Metro Plan formula is a "pharmacy" benefit.

The fine folks at CVS.com are now sending the formula on its way for $35 shipping and a $10 co-pay. WooHoo. (If I wanted to carry 50 pounds of this stuff from my local CVS I could ahve picked it up and saved the $35 shipping, but I figured my aging back was worth the shipping fee).

And since the CVS.com folks were far, far, far more helpful that my local pharmacist of 20 years, guess where I will now be filling all of our presciptions.

I have ALWAYS been a proponent of shopping locally and supporting small local stores, and will continue that. Just not in this particular case.

Susanna said...

dreck, what a nightmare!

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