“Your drugs are too expensive.”

That’s basically what United Health Care had CVS tell Kelly when she went to get a scrip filled. Kelly has taken the meds for three years. Her past two insurance companies covered the prescription without fail.

Now United Health Care has decided the drugs are too pricey, and, “…since a generic is not available, they’ve decided the best way to prevent paying too much for their clients’ medication is to put limits on how many pills they’ll pay for per client, per month,” she writes.

Kelly needs to take 1.5 pills per day, 45 pills per month. United will only cover 30.

That’s not the worst of it.

The pharmacist told her that if the pills are a medical necessity, as they are, she should have her doctor call the insurance company and explain the need for the medicine.

Kelly said to the CVS pill pusher, “An authentic written prescription from a medical doctor is not proof enough of medical necessity but a phone call with no real explanation will make giving me 15 more pills OK?”

The white coat affirmed this was correct. In addition, if United ultimately determines not to cover the 15 pills, the cost would be $50.

This practice seems pretty ridiculous and arbitrary on United Health Care’s part but we have to ask, if you’re going to switch providers, shouldn’t you find out whether they cover the medicine you’ll be needing?

Kelly’s letter is inside.

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Kelly writes:

“My Dearest Consumerist,

Armed with a brand spankin’ new UnitedHealthcare insurance card, I headed to my local CVS to fill a prescription. I’ve taken this particular medication for the last three years and my two prior insurance companies never gave me any sort of hassle where this medication was concerned.

I handed my prescription and my new insurance card to the pharmacist and he told me it would only take a few minutes to process the new insurance. A few minutes eventually turned in to fifteen before he came from behind the counter to tell me my insurance wouldn’t fill the entire Rx. Obviously confused, I asked him to please elaborate. As it turns out, this medication is deemed too expensive by the insurance company and, since a generic is not available, they’ve decided the best way to prevent paying too much for their clients’ medication is to put limits on how many pills they’ll pay for per client, per month.

My Rx called for 1.5 pills to be taken daily, meaning 45 pills would be needed for an entire month’s supply; United will only cover 30.

I further questioned the pharmacist as to what I could possibly to do get United to cover the medication, as it’s absolutely necessary that I take it. His explanation, essentially, was this: call your doctor’s office and have either the doctor or a nurse phone the insurance company. All they need to do is explain that the medicine prescribed is medically necessary and, 9 times out of 10, they’ll approve it.

So I said, “wait a second. An authentic written prescription form a medical doctor is not proof enough of medical necessity but a phone call with no real explanation will make giving me 15 more pills OK? That makes absolutely no sense.” The pharmacist apologized, agreed that the system was backasswards, and also told me that should United not cover the additional 15 pills, I would have to pay roughly $50 out of pocket for them.

$50 is certainly not going to break the bank and I’ll pay it if I absolutely have to. I understand that healthcare is expensive and that maybe, to some degree, the insurance companies MAY have to cut back in some areas. I, however, don’t think it’s right to say that a prescription for a medication used to treat a bona fide illness isn’t enough to have said prescription filled. It utterly baffles me!

Just thought I’d share another consumer’s plight. Hopefully there aren’t too many other people out there with similar situations but somehow I doubt it!

Love always,
Kelly”

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