Insurance company/CVS Specialty pharmacy weirdness/scam

A member of my immediate family is on a slightly unusual prescription medication that we’ve been getting through our insurance (provided through my employer) and delivered by CVS Caremark. We’ve gotten it with little hassle for years. On the latest refill, somehow our prescription changed from CVS Caremark to CVS Specialty, and our co-pay for a 3 month supply went from ~$90 to ~$3000. Calling and calling around and around, finally we got someone to manually change it back to CVS Caremark, and they say this will restore the normal copay. We should be able to confirm this worked in a few days (they say).

AFAICT this sounds like a big-company scam – no one could explain why it changed from Caremark to Specialty, and no one could explain why the copay is so massively different between the two. It sounds to me like the pharmacy (or the insurance company – not sure which) arbitrarily changes things like this every so often that can justify much higher patient costs in the hopes that we don’t notice or call them on it. Anyone else have experiences with anything like this? Very frustrating.

Sounds like par for the course. We have to use CVS Specialty for one of my daughters medicine. Though I’ve not had this particular issue happen (I had no idea that alone would make the co-payment larger).

Its seems fairly typical of the kind of Kafka-esque, expensive, bureaucratic screw ups that happens every couple of weeks with my daughters treatment. That then requires an hour or two at least on the phone with one or more of the huge faceless bureaucracies involved (insurance, pharmacy, hospital, or multi-national medical company running one of the medical groups)

But remember if we can’t have universal health care or we’d have to deal with a huge faceless bureaucracy just to get basic healthcare :frowning:

Off the top of my head, I would guess it was database error caused by a less than cautious IT person. I can imagine someone running a query that changes all records with certain criteria from Caremark to Specialty, but not being precise enough with that criteria and causing collateral damage. This would also explain why no one answering a phone could tell you why it changed, it was some IT person in the background doing database maintenance and not a policy change.