Far too lame to pit, and I’m not even angry anyway, just tired and annoyed and wanting to bitch.
I lost my coverage (Horizon BCBS Direct Access, with prescription drug coverage “carved out” to Caremark) after my divorce in mid-December. COBRA extends back to the day you lost coverage no matter when you enroll, and it’s pretty expensive, so it’s usually a good idea to wait and see if you’re going to actually use it before enrolling. That decision was made for me as soon as I picked up a refill of one of my medications and discovered that it’s $346(!) out of pocket for a 30 day supply.
My ex’s company uses a COBRA administrator called Ceridian. So I enrolled with them online, and once I started receiving bills, paid them directly. They in turn sent the enrollment and money on to Horizon. After a month or so (and another out of pocket payment for the same prescription), I called up to find out why I hadn’t heard anything, and discovered that Horizon didn’t have any record of me. After enough prodding at them and my ex’s incompetent HR person, they figured out it was because they needed a physical enrollment form because they didn’t have individual information about me like my birthdate. (:rolleyes:) I filled out the form, and a couple of weeks later Horizon finally processed me onto their system, and in turn sent my enrollment over to Caremark. And I was at long last able to fill that prescription for just the copay, like a normal person! And able to fill all the others, which thankfully were on 90 day cycles and, with the help of samples from the doctor’s office, were only just starting to run out.
I also went ahead and filled out the paperwork to get that $700 out of pocket cost refunded, which requires you to send in either the original receipts or what looks like a shitload of paperwork filled out by your pharmacist. Fortunately, I had known to keep the receipts, so that wasn’t a problem.
Last weekend I (stupidly) ran out of that same troublesome prescription, which I knew was almost gone but I hadn’t realized was also out of refills. I simultaneously received a letter of denial from Caremark for the refunds, due to something marked as “Plan Limitations Exceeded”. I had my doctor call in a temporary refill a couple of days ago, which I was going to pick up today, and finally got enough past my annoyance to call Caremark just a little while ago.
It turns out that “Plan Limitations Exceeded” means that, as of 1/1, they no longer allow a quantity of 60 for a 30 day supply, which has been my prescription since at least this time last year. When I questioned how this could be, since I had filled it under this insurance just last month, it turns out… well, it still doesn’t make any mathematical or timing sense to me actually, but apparently the pharmacy had somehow gotten them covered as a couple of 15 day supplies or something. It apparently hadn’t occurred to said pharmacy to mention the problem to me at the time so that I could fix it - perhaps because I had gotten other refills of this from them this year? IDEK.
After a lot of probing questions (to what was actually a very helpful Caremark customer service person), I found out that I need to get my doctor to get the prescription “preauthorized” as medically necessary. “Preauthorized” is in quotes because my doctor will need to very carefully specify that this is retroactive to the beginning of the year in order for me to get my refund. This authorization actually needs to happen via Horizon, who will then send it onto Caremark on their normal every-few-days electronic feed. Once this all goes through, I will be able to pick up my new prescription for this month without paying out of pocket again. Unfortunately, I will also need to resubmit the paperwork for the refunds from scratch. As I no longer have original receipts (since I sent them in before, remember), I will apparently also have to go through getting the pharmacist paperwork as my proof this time.
Interesting (or not) related notes:
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I called Horizon to double check the fax number and process, and their customer service rep tried to tell me that my doctor needs to do the preauthorization with Caremark instead. After some argument, he got off then phone for a few minutes, then came back to grudgingly admit to me that it really is through his company after all, and gave me the phone number my doctor needs to call instead of faxing.
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Apparently my doctor also needs to specify that it can either be 60 for 30 days or 180 for 90 days, since these don’t count as the same thing to Caremark’s systems. Again, IDEK.
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Please note that I’ve been paying $550 a month for my coverage all this time, which Ceridian has been quietly, correctly, and efficiently processing behind the scenes. I’m not sure if that means that Ceridian is that much better than the rest of them, or that people are always willing to take your money if you’re willing to pay it.
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Ironically, I had already been planning to ask to lower my dose to what would be Caremark’s acceptable amount when I saw the doctor next, which is now this coming Tuesday. But I still need this preauthorization to happen in order to get my money back. I apologized profusely to his assistant over the phone, though she seemed cool with it.