Oxford Tweaks Rules So It Can Double Your Monthly CoPay

Kristine writes:

Oxford healthcare recently updated its policy to read that no dosages of prescriptions exceeding 31 days would be processed. In the case of a patient receiving injectable solution, this may mean that their reconstitution device will give them 18 days of dosing, meaning that they will have to pay two copayments per month in order to receive ample supply of their medication…

This came to my attention because my son has congenital growth hormone deficiency, and receives daily injections of human growth hormone. The cartridge comes in an 8.8 mg vial, and my son receives .48 mg per day, so each vial lasts 18 days. Because two vials would equal 36 days worth of medication, Oxford will only allow the pharmacy, ICORE Healthcare, to ship my son’s medication every two weeks. Therefore, instead of paying a $50 copayment every month, we need to pay $100, a $50 copayment every two weeks. I find this unjust and unfair, and filed a complaint with the Consumer Services Bureau. It’s just another example of health care companies taking advantage of patients who are forced to pay unfair copayments because they need their medications.

Kristine
Wappingers Falls, NY

Nudge nudge nudge, tighten, tweak, twist; by a thousand small alterations the insurance company changes the rules so you pay more money and get less in return.

(Photo: Getty)

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  1. SuffolkHouse says:

    Great! And who was the moron arguing that class warfare gets you nowhere?

    This crap needs to end, and it will when people figure out that they are pretty damned powerful.

    “Brothers with their AKs and their 9Ms need to learn how to correctly shoot them…”

    Arrested Development

  2. JustAGuy2 says:

    A 30 day limit really isn’t unusual. Why isn’t she blaming the drug manufacturer for not making 14.4mg (or 7.2mg) vials?

  3. heavylee-again says:

    What is that picture, and what does it have to do with yet another large company taking advantage of it’s customers?

  4. Juggernaut says:

    Same thing here with insulin… Horizon would not pay for 3000u monthly because I only used 2700u and they couldn’t give me a 33 day supply. My pharmacist and I had to work out a combination that we could all live with and it turned out insurance would cover 4500u for 42 days. Instead of paying $20 copay for 15 day supply, I now pay $40 copay for 42 days… talk to your pharmacist and see if you can make it work…

  5. CRNewsom says:

    @heavylee-again: I think you mean maximizing profits.

    It does the company no good to treat you like crap if you could go somewhere else and get treated differently. So, all the companies try to maximize profits. To do that, the premium must increase, or the service rendered must decrease. If you want better coverage, you had better get ready to pay higher premiums. I’m not siding with the company, but insurance companies are based on a for profit business model.

  6. Conan the Electrician says:

    If you don’t like paying an extra $50 a month in copay, you are free to not use the company and spend thousands of dollars to buy that medication on the free market.

  7. azntg says:

    I can’t help but think that there has to be a point where a government-run national healthcare program, as inept as it will inevitably be, will actually be more attractive than the privately run healthcare programs at the rate we’re going.

  8. Gotta love the health insurance companies. No other group can make compassion sound so evil…

    Starting in June, our pharmacy copayments (50%) will no longer count towards the yearly maximum if the drug is classified as a maintenance medication. So most anything other than a one-off prescription won’t count towards the yearly $3000 limit we have to pay. That’s not really a problem if you’re taking generics or a low-cost named drug, but if you’re on HIV/AIDS medications, you could spend upwards of $14000 a year out of pocket. Or die.

  9. SuffolkHouse says:

    @dabusdriver:
    Probably not so free. He probably couldn’t afford doing that.

    Are you suggesting that because he might have no choice, that he shouldn’t be pointing out a flaw in the system?

    That seems foolish to me.

  10. @dabusdriver: Or find a different supplier that delivers in a different dosage. I know my brother got his in vials that each lasted a week.

  11. JiminyChristmas says:

    I’m sure you would have to get really deep in the weeds of this woman’s contract of coverage to find out whether or not she is really being ripped off. That said, the one copay = one 30 (or 31) day supply of a prescription is a standard health insurance practice.

    If the drug is only dispensed in a manner that provides a patient with an 18-day supply I don’t see how that should just be a bonus for the insurer. If the converse were true, say if the only way a drug were dispensed gave you a 40 day supply, I’m certain the insurer would find a way to charge you.

    If you ask me (not that anyone did) the most straightforward solution would be to pro-rate the co-pay so the policyholder is getting a one month supply for one copay. Of course, that would require the insurer to offer their customer an individualized solution rather than treating them like another faceless ratepayer who is lucky to have insurance in the first place.

  12. Sherryness says:

    “Ample” means “more than enough.” You might want to re-word that to say “adequate.”

  13. bohemian says:

    PBS is doing a series on other countries health systems and how they work both good and bad.
    [www.pbs.org]
    NPR is also doing radio bits in the afternoon about other countries health care systems.

    I spent a good six months figuring out all of the loopholes in our previous insurance so as to get screwed less. I am still four months later trying to figure out all of the loopholes in our new insurance.

    I want Japanese health care…

  14. LAGirl says:

    i had a similar problem with migraine medication. Blue Cross decided to switch the 30-day supply from 12 to 9. the difference of 3 pills in a month for a migraine sufferer is very serious. could mean a trip to the ER. didn’t really make sense to me. would Blue Cross rather pay for an ambulance + ER rather than 3 lousy pills?

    however, there is a way around this. your doctor can fill out a pre-authorization form for that medication. he just provides some basic info, including other similar medications that you’ve tried, but didn’t work. the point you’re trying to make is that you’ve tried everything else, and this medication is the only one that works.

    the first time my doctor filled it out, Blue Cross rejected it. we did it together the second time, and included very detailed info. it was approved. this doubled my monthly quantity. haven’t been to the ER since.

  15. I wonder if this applies to Medco-filled Rx. I always get a 90-day supply of Nexium for $100. I think Medco is run by Oxford (which is really United Health Care by any other name, probably the best company in the US at benefit prevention). hm, I better check into that,

    look, it’s fair to bitch about all of these little things that add up, driver-whatever, because we’re all paying increasingly-higher premiums for increasingly-less coverage. go rip a page out of Atlas Shrugged and smoke that.

  16. RINO-Marty says:

    My understanding is that 90-day supplies are a perfectly common option. Like Greeniusatwrok (eh?) I use Medco and get 90-day supplies.

    Dabusdriver: You are some special kind of stupid. The OP *is* in the free market. Her health insurance company is a private company. The point – which you are too obtuse to recognize – is that health insurers make hazy promises, like the copay for a month’s worth of drugs is $X, and then play games with the rules to weasel out of their obligations. If this woman works fulltime, the insurance is probably offered through her employer. If she’s buying insurance on her own, she’ll never, ever, ever qualify for a new policy with a new company. So her son will die or she’ll pay more than she was led to believe when she signed up.

    Here’s another fun trick insurers use to screw their customers: They don’t officially “approve” procedures until after they’ve been performed. In most cases there’s no such thing as pre-approval. When you call in advance of a surgery, for example, to verify coverage, all you’re being told is that that one particular representative believes, at that moment, that you’ll get paid. But when the bill comes, if a different rep comes to a different conclusion, they’ll deny coverage. And there’s nothing you can do about it but appeal and hope that a third or fourth or fifth rep agrees with the first one.

    I went through this once with Cigna (a story was posted here about it) and I even checked with my state’s insurance commission. The bottom line, according to them: binding pre-approval does not exist, and if you don’t like it, you can go jump off a cliff. The end.

    Nationalize these bastages.

  17. KogeLiz says:

    I thought this was normal?

    This situation happened to me a few times, but my doctor contacted my insurance company and after that, I was able to get two bottles of medication a month with only paying one co-pay.

    You may also want to contact the drug manufacturer about this problem as well.

  18. Orv says:

    Some doctors are getting around this by writing the prescription for double the actual dosage, then telling the patient to only take half.

  19. jimconsumer says:

    @azntg: Do you think 50% tax rates are attractive? Neither do I. Look, I think the insurance company is being a jerk, too, but let’s not get ridiculous here and start calling for HillaryCare. If Kristine thinks an extra $50 a month hurts, wait until the government is taking half her family’s income to pay for everyone’s “free” health care.

    The answer to this problem isn’t politically correct: Simply, her son has special needs, and they’re going to cost her more money than other children cost their parents. The medication likely costs hundreds to thousands of dollars per month. She should be happy to pay only $100 for it. Neither the government, the taxpayers nor the insurance company promised her a free hand out should her child require special needs, and quite honestly, the rest of us should not have to bear the burden.

    This isn’t intended to sound cold and heartless. Certainly, if her family were poor and unable to afford the medication, the rest of us must step up to the plate and foot the bill to help care for the child. In the absence of severe financial burden, however, it’s OK to tell folks in this situation, “Suck it up and pay.”

    My daughter had crooked teeth and required braces. Insurance only covered half, I had to cough up $2,500. My allergy medication runs me almost $100 a month in co-pays. I don’t ask the taxpayers to foot my bill, I just pay it. I’d bitch if they doubled my copays, sure, and I do think Kristine’s complaint is valid, but the answer is not some form of government health care, as you suggest. Times are tight for everyone and she may just have to suck it up and pay the money.

    It’s perfectly acceptable to ask people to pay their fair share – if they need special care, they should pay extra for it assuming they’re not legitimately unable to do so.

  20. LUV2CattleCall says:

    @jimconsumer:

    Exactly…thanks! For anyone that disagrees, I suggest you look up the words “Supply” and “Demand”

    @Orv:

    I have a ton of family in the medical field and they usually do that if the patient asks. That’s the key though…the docs can’t offer to do that, but if you ask nicely, most will oblige. Somewhat like the “Car Service” at the airport has to turn you down if you ask for a taxi, but if you ask for transportation, they’re good to go…it’s all in the semitics.

  21. jimconsumer says:

    @RINO-Marty: Nationalize these bastages. – I agree insurance companies play games that ought to be illegal, I just don’t think “free” government health care is the answer. I do think we need to tear down the current system and build something new and I’d support government interference in this market if done right. Insurance companies are allowed too much freedom to screw people. I can’t support “free health insurance for everyone” games. We’re overtaxed as it is.

  22. zerj says:

    “A 30 day limit really isn’t unusual. Why isn’t she blaming the drug manufacturer for not making 14.4mg (or 7.2mg) vials?”

    Because for the person who requires 30ml per day the 7.2mg vial is perfect. Should the drug manufacturer make every possible vial size?

    The real solution would be to prorate these copays by the # of day supply. So instead of being charged $50 per dose she is charged 50*18/30=30 per dose. It’s a lot easier to divide dollars and cents than it is to divide actual fluid in a vial.

  23. angelcake says:

    While my issue with Oxford isn’t life threatening or as serious as the original posters, my issue is their policy regarding the allergy pills.

    Since Zyrtec and Claritin are over the counter I must only use them. My doctor prescribed Allegra D for me and Oxford refuses to cover it. The allergy pill situation is another disaster altogether with the ‘meth’ lab law and idiocy. Like these meth manufacturers are paying 12 dolllars a package? Please, they’re importing from Canada in bulk.

    Yet I’m paying for someone’s Viagra. Sorry, if it doesn’t work on its own maybe nature is trying to tell you something. My eyes itch, my nose is constantly running, and my throat hurts, almost 6 mothns or more of the year. And I can’t take what my doctor prescribed to me unless I want to fork over $150 for one months supply.

    Can’t we do some kind of CLass Action against these damn health insurance companies? Fraud, embezzlement, misappropriation of funds…that’s just off the top of my head. My insurance payments should go into a fund for medications I may need. Not someone else’s Viagra.

    just my 2 cents.

  24. Conan the Electrician says:

    @SuffolkHouse

    The woman is basically complaining about price. My point is that if you don’t like the price of something, go elsewhere to buy it or a substitute. Of course, she can’t do that, because the company is way undercharging her for what the product actually costs. Supply and demand is distorted in her favor, so why is she complaining.

    It’s like farmers getting subsidized water below cost, and then complaining when that farm subsidy is reduced slightly. Oh wait.

  25. ThunderRoad says:

    Zyrtec is available in generics. $10/90 pills at Walgreens. Zyrtec D is still pricey (no generics) but can be had for about $19/24 pills. My fiancee’ needs Zyrtec-D and is getting raped compared to what her copay used to be ($30/90 days) when it was prescription only.

  26. juri squared says:

    @Juggernaut: I had a similar issue. I’m on a medication that comes in 30mg and 60mg doses, but I need to take 90mg per day. I’d get charged two copays to get one of each, so I just take three 30mg pills per day. It’s asinine, but it saves $50/month.

  27. rlee says:

    I have a similar problem with Aetna. I wouldn’t mind paying double the co-pay to get 2 months worth instead of 1, but the pharmacy swears Aetna won’t let them! They also can’t refill more than a week early, unless I ask them to request special permission from Aetna because otherwise I’ll run out while I’m out of the country. Why does Aetna do this???

  28. SuffolkHouse says:

    @jimconsumer:

    Your allergies and your kid’s oral aesthetics don’t look anything like my dead uncle. How’d he die? He had a full time job, without insurance. He put off going to the doctor and died of a diabetic heart attack. His diabetes had never been diagnosed.

    50% taxes is a myth. Support it. Second, the democrats have proposals that involve only private health insurers, do your GOP drivel doesn’t stand up anymore. There will be plenty of profit from illness to suit you and others.

  29. angelcake says:

    @ThunderRoad- Like your fiancee, I also have to take the ‘D’ versions of the allergy pills. I was on Zyrtec-D before it was over the counter and my doctor thought Allegra-D might work a bit better. But yeah, the price of Zyrtec D now that its OTC is insane. I did see at CVS that generic is ‘coming soon’ at 11.99 like the generic Claritin D.

  30. JiminyChristmas says:

    I agree that universal health coverage = OMG the taxes!!! is a baseless scare tactic. Plenty of other industrialized countries spend 30%-50% less per capita on health care than the US, and perform better on almost any measure of public health.

    Look at it that way, and we should be able to muster up the same level of (non-)care we have now for a hell of a lot less than we’re actually paying.

    Or, you could look at it this way. I have a pretty median income. The government could raise my federal income tax by 45% and it would be no more than what I pay now in income tax plus insurance premiums. Alternatively, you could multiply my Medicare withholding 4X and get the same result.

  31. RvLeshrac says:

    @dabusdriver:

    Ah, yes. Undercharging her. Which is why we pay $50 for a prescription that costs nearly nothing in every country EXCEPT the US.

    You’re totally ignoring the fact that the drug companies spend as much or more in advertising than they do on R&D/manufacturing.

  32. RvLeshrac says:

    @jimconsumer:

    Crooked teeth? Braces? That’s cosmetic and unnecessary.

    You’re comparing a cosmetic procedure to a “take it or you die” medication.

  33. TBT says:

    Oxford also used to allow your DOCTOR to decide what was an appropriate dose of medication. About 8 years ago, they decided that the dose my doctor prescribed simply was too much, and they would only allow a 21 day supply of prozac every 30 days. They abolished the “override” rules and decided they were more qualified to decide how much suicide-preventing medication i needed. Luckily, I switched insurance companies not long after, but this is not a new issue.

  34. ben1711 says:

    This is a size matter…due to package size restrictions the matter is either going to go in favor of the consumer or the insurance company. One of the 2 is going to “rip off” the other because it will not be an exactly 30 day supply.

    Simply put, it is either:
    50 dollars for 18 days
    50 dollars for 36 days

    The insurance contract states no more than 31 days at a time, so guess who wins.

    Unfortuate for the consumer…yes. A cruel insurance company…no.

  35. RokMartian says:

    @rlee: I have Aetna, and I can get 90 days no problem. But I do have to go through mail-order to get it. I get a discount when I go to a pharmacy but I don’t get a deductible. (it is not much)

    A lot of people may not realize that the coverage is really dependent on what your employer decides to pay for or cover themselves.

  36. VA_White says:

    I have the same issue with my injectable meds. One vial is 17 days, two vials are over 30 days. But my doctor is cool. He writes the prescription so it comes out even and we have an understanding that I take less than the overwritten dose on the package. Because the higher dose is an acceptable dose of my meds, there is no way insurance can say it’s too much. I just happen to need less per shot. My meds last the whole month and I only pay one co-pay.

    For every way the insurance people can come up with to screw you, there is a way to screw them right back.

  37. zgori says:

    Insurance companies love to play these games. You just have to get the doctor to rewrite the prescription to their specifications. They’ll do it.

    Fun trick — if he’s willing, you can also ask him to write other prescriptions for double the dose and cut the pills in half. They last twice as long, you make half as many copays.

    It’s a big game. Patients, insurers, prescription service companies and drug companies all trying to screw each other. No reason you shouldn’t get in on the action.

  38. banmojo says:

    (Approximate amounts)
    1. Amount the USA amasses annually for healthcare: 1.23 trillion
    2. Amount the insurance companies pocket OFF THE TOP AS PURE PROFIT I’M NOT TALKING SALARIES HERE: *drum roll*

    Anyone know the true figure? It’s out there. Why don’t you know it? Here it is: 40-45%.

    Boom.

    Just think that over for a few minutes, then PLEASE get as angry as I am and call your damn representative and I’m NOT KIDDING. The money is OUT there to pay for everyones healthcare in America, but the legally corrupt bastards in the insurance game are f$#@ing us HARD in the A without KY.

    40-45%. Take out your calculator and figure that one out.

    Free market is one thing. Highway robbery and strong arming (as if any of us really have a choice at this point) is really another thing altogether.

  39. Vicky says:

    @rlee: My insurance used to always balk when I went to fill my birth control prescription, which comes in 90-day packs. I’d end up paying a copay for the equivalent of 30 days and full retail for the remaining 60.

  40. JustAGuy2 says:

    @banmojo:

    Where on earth did you get that 40-45% number? That would imply about $500BN/year in profit, which is WAY high.

    Take an example. United HealthCare generated about $4BN in profit on $75BN in sales. That’s 6% margin, not the 40-45% you claim.

    There’s an argument to be made for single-payer health care, but it isn’t going to be made by yanking numbers of out the air and outright lies.