I have United Healthcare, and I have to say I've seen this happen to me as well. I'm on a long term maintenance medication, which is delivered by patch. I was on the generic in my previous health plan, so my new doctor prescribed the same generic.
I used the mail order pharmacy and they told me that a 90 day supply would cost $347. I asked why it was so much, and where my prescription benefits came in. 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.
I called my doctor, and got them to change the prescription. None of the people at United Healthcare were offering any of this information, and I basically had to pry it out of them to figure out why they were trying to gouge me. Also, this was their own private mail order pharmacy, so all the money was going to them as well.
Ask a lot of questions before paying a lot of money.
"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.
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.
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.
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)
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...)
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?
Interesting, or a similar phenomenon to situations where in order to maximize deductions you might want to increase charitable contributions, better to give the money to a friend non-profit than Uncle Sam
Generic neurological drugs are not reliably consistent. The allowed variations and additives can and do play havoc in some people. Even something so simple as coloring can be a problem.
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.
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.
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.
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.
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.
> 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.
>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.
BriovaRx I assume? These guys are the worst. OptumRx (might be who you have through United as well) screwed me over because no one ever explained to me what the hell a "specialized" medication was.
I was put on a $drug and so when asked where I wanted to fill it I told my doctor to send it to my local Kroger Pharmacy. I went and tried to use my insurance but it wouldn't run for this $drug. I called OptumRx (the number on my healthcare card) and they said it should work. I gave them all my info, they assured me Kroger Pharmacy was In-Network, and they had me stand in line again so that they could talk to the pharmacist. No one could figure out what was wrong so the pharmacist gave me 3 pills to get started and OptumRx told me it would be cleared up by tomorrow and they would call me. Day 1, no call. Day 2, no call. Day 3 I call the pharmacy and they say they haven't heard anything from OptumRx, I called OptumRx and they finally realized that this $drug is a special drug that can ONLY be filled by their online pharmacy BriovaRx. I get transferred to BriovaRx and they say they can mail me the drug in 2-3 days and I tell them that's not going to work because I took my last pill today and there aren't supposed to be any breaks in the medication. Finally they cave and call in an "override" so I can get it from Kroger this one time.
They also fucked up a delivery once and told me they couldn't send more pills until they figured out what happened to the last package (which could take days) and I was 1 pill away from being out. I had to fight my way through people telling me there is nothing that could be done about it until finally, again, someone called in an override. Mail order may be nice and all but when I can't re-order until I'm less than a week out and shipping doesn't always work as expected it's a huge PITA and a big stressor. I order EVERYTHING off Amazon so trust me when I say I prefer the idea of mail order but when I need a medication I want to be able to walk down to the Kroger Pharmacy and fill it instead of waiting for something that might not come on time.
There was a recent, interesting discussion on econtalk that I think I'd related to this. In order to get a generic approved you need to proof bio-equivalence. To do that you need three original drug. The original creator of the drug has interest to delay this as long as possible. So they use the special drug thing to make it really hard for their competitor to get the drug. Sounds totally insane but apparently is common now. The original intend of the special drug thing was to protect people from more dangerous drugs that you need to be well informed about.
Sorry, phone auto correct. As someone else pointed out it should be "the original drug". You get both drugs and show that they are the same for the body.
Mail-order pharmacies are the worst. I understand what they're trying to accomplish WRT costs, but I've never encountered one that could actually deliver consistently and on-time. Frequent delays for no good reason, no express shipping, lost paperwork, etc. It's a mess.
I would still check prices on your pharmacy benefits site between mail order for 90 days and a local pharmacy. The mail order pharmacies are frustrating, but typically you pay less for a 90 day supply.
This might be a stupid question, since I don't know how the US system works - if you have health insurance, why do you have to pay anything for drugs "covered" by your insurer? If they cover a medication, why is there anything left to be paid by you? Do you also have to pay if you have any treatment that is "covered" by your insurer?
As an example, I have a 4500 dollar deductible. That means until I pay 4500 for prescriptions, doctor visits, labs, ER visits, etc., insurance pays nothing, though I do get their negotiated "discount" from the provider. After that, the insurance pays 80% of the cost until I have paid out some even larger number, at which time they pay 100% until January rolls around.
This is a pretty normal plan, and the type the guy you're responding to is describing; older plans often have much lower deductibles and have copays, though premiums tend to be higher, but one they're hard to find now.
It's very easy to meet a 4500 deductible. I've already done it for the year without any major health events.
Switzerland has the same system with deductibles and after that you need to pay 10% with a maximum of 700 per year.
Cost is about 220 per month for a insurance with 2500 (max allowed) deductible and 320 per month for the one with 300 (lowest allowed) deductible.
I mean, the reason I asked is that I can't imagine paying anything for any treatment or medication. The thought that you pay for private health insurance and yet have to pay anything for medicine/treatment is super weird to me.
It's not arbitrary, the deductibles and copays push down the monthly premiums.
Under the ACA, the cost sharing is standardized, so it isn't simply a matter of the insurance company enriching itself or anything like that. This document discusses how the standardization works: https://kaiserfamilyfoundation.files.wordpress.com/2013/01/8...
The idea is because you have to pay a little bit out of your own pocket you are less likely to run to the doctors and get a prescription when nothing is wrong. Since it is your money that you could spend on something fun instead of a pill you will ask do you really need to buy the pill, or will a cheaper pill work just as well. Note that the above is the idea - there are various problems with it, but the idea makes some sense.
There is a real problem with some people going to the doctors and demanding a pill to fix some problem, doctors get tired of seeing this person and prescribe something relatively harmless just to get them to go away.
Doctors used to prescribe antibiotics for viral illness as well because people expected a pill from the doctor.
Some old people have no friends left so talking to the doctor is the only social life they have.
Do not confuse the above with with cases where there is something wrong and the doctor cannot figure out what.
The co-pays for some drugs can get pretty steep for people on fixed incomes like social security. If the only reason is to keep people from nagging the doctor, you'd think that the co-pays would be fixed instead of varying wildly depending on the drug.
Health insurance plans have varying coverage for drugs (and those plans can vary a lot state to state), so that's going to depend on the plan. Decent plans typically pay everything but a very small charge. Average plans often have limits to routine prescription drug coverage in a given year.
A medication I took last year cost around $90-$100 or so. The insurance covered all but $10 of that.
I had a similar situation with my mail order pharmacy. Ordered a 90-day supply of maintenance medication, was charged brand rates against my deductible. They dispensed the brand rather than the generic. Asked why, they said, well, we have a deal with the company, you get brand drugs at the cost of the generic co-pay! They neglected to understand that some of us don't have co-pays for Rx, and pay the actual cost. Solution? Go to Costco, get 30-day subscription, pay pennies per pill.
Just because it's their own private pharmacy doesn't necessarily mean they follow a different set of rules. The PBM probably has that pharmacy set up like any other and treat it as a preferred pharmacy with internally negotiated discounts.
I used the mail order pharmacy and they told me that a 90 day supply would cost $347. I asked why it was so much, and where my prescription benefits came in. 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.
I called my doctor, and got them to change the prescription. None of the people at United Healthcare were offering any of this information, and I basically had to pry it out of them to figure out why they were trying to gouge me. Also, this was their own private mail order pharmacy, so all the money was going to them as well.
Ask a lot of questions before paying a lot of money.