Steve,
I’m have exchanged messages with you before. Our insurance company just sent a notice saying that they will only allow 60 tablets for a 25 day period of my husband’s class II narcotic rather than the 90/month the doctor prescribes. A statement follows this saying that the doctor can prescribe more and nothing will prevent us from filling a higher number. However they will only pay for the 60 allowed. They also say that the doctor can call them to get approval for a higher number, but that they will still only pay for the amount stated. This doesn’t go into effect until March 1, but I discussed it with our independent pharmacy today. We are willing to pay for the extras that the insurance won’t pay for, which actually calculates out to 18 additional tablets/month. ( they are allowing 60 for a 25 day period which translates to 72 for 30 days). However, the pharmacist said that the DEA won’t allow us to pay cash for the additional number. Is this true? How could I confirm this? Who should I call? We can pay for the additional and would rather do that than have his dose reduced yet again. Thank you.
What this insurance company is doing may be creating a “mine field” for everyone but them. The DEA considers it a RED FLAG for a pt to pay cash for a controlled substance prescription when they have insurance. Nothing would indicate that the DEA will make an exception for that RED FLAG under this particular situation.
Then there is the situation that pharmacy software sends the prescription to the insurance company and normally if the days supply exceeds insurance company’s limits, it is just rejected for payment. That would mean that the pharmacist would have to fill a single paper C-II prescription TWICE.. assigning it two different prescription numbers… billing the allowed quantity to the insurance company and the second for CASH.
This is going to send two different prescriptions to the state’s PMP for the same medication twice on the same day by the same doctor, pharmacy and patient. Is this going to throw some RED FLAGS by the PMP ?
I am sure that this pt can call the BOP and the DEA and they may or may not get a answer, but I suspect that neither would be willing to put the answer in writing.
If this pt is covered by Medicare/Medicaid they can file a grievance with www.cms.gov 800-MEDICARE or if the insurance is a ERISA policy that means that the “insurance company” is just administrating the payment of the bills with the company’s money and someone within the employer can probably tell the insurance company to pay these types of claims and remove the quality limits on these medications.
Then there is the state insurance commissioner to file complaints with.
The pt can also review their policy – which is a contract – and see if they can find a statement in the policy that states that the insurance will pay for “medically necessary treatments”
Filed under: General Problems
Funny this subject came up! I get Disability but it is SSI so I get medicaid. This has never happened before but I had to get another 6 month pre-auth which was supposedly done. I went to fill my two prescriptions yesterday…the one went thru, the other didn’t. While going back and forth to the Dr. and drug store, I called my insurance. The reason? By submitting the 2 controlled scripts together I went over the limit. The limit of what I am not sure. The MME is all I could figure as I never had this come up. The drug formulary is still the same as I checked it last month. AND I was cut back again!! So another pre-auth has to be done again for that med. This is really getting ridiculous! I am not allowed to pay cash either. What’s the friggin difference?
Watch it,,to whom=ever wrote Steve,,,my insurance cvs-caremark pulled the same thing,,I did not do it this next scripts,,pay cash,,Im going to my Docs 1st,,,for if they red flag u,,and actually its not ,”if” they will,red flag u,,,,u will loose it all.,.,,,your Doc,,your medicine,and u,,,for u will loose ur meds,,thus not function,,Soo,,i’d figure something out w/your Doc,,,,before payen cash again,..Like I said,,no wonder my pharmacies of 30 years retired,,She saw the writing on the wall,,,maryw