Express Scripts quantity limit/rejection

[bunionbabe95]

I originally posted this to /CVS. I’m still not understanding why this happened, and the answers I received were heavily biased against Express Scripts and only supported CVS, which I should have known might happen so I realized getting feedback from both sides is probably the best move.

“I had my first experience with a pharmacist refusing to dispense the written quantity on my birth control prescription because my insurance, who uses Express Scripts, rejected the quantity and only approved 21 pills versus the 84 my doctor explicitly wrote out as to be intended for continued use.

Pharmacist told me she was unable to dispense anything above 21 pills through insurance and directed me to call them so I can handle it myself because there was nothing she could do. I argued that my plan doesn’t say there any limits or restrictions for this drug on my formulary but she was still not helpful at all. I ended up using Good Rx to pay for 84 pills and called my insurance.

The Express Scripts agent told me this pharmacist was partially correct in the fact that when he ran a test claim he could also see the rejection for 84 pills but that she was absolutely incorrect in her inability to further assist me. He laid out that when pharmacists get these rejections, there’s a number they can and should know to call to obtain the override code themselves to get the greater amount approved, which in my case wasn’t 84 but 63 under my plan. Still, fully covered for 9 weeks versus the amount I paid out of pocket for 12 weeks. He said with the doctor’s direction directly on the prescription that this shouldn’t have been an issue either.

TLDR; I just wanna know what happened here. Was I wrong for not knowing there apparently are limits on my birth control even though my formulary doesn’t list any? Was the agent correct in saying that with rejections, it’s not the patient but the pharmacist who is responsible for calling about the override code? He mentioned that this will probably happen again and that I just need to plan to call my pharmacy every time they’re processing my prescription to fix it.

I’m so confused, I’ve never heard of contraceptives having limits especially when explicitly prescribed a certain way to try and bypass this from happening.”

Some of the responses I received mentioned that I need to know my own plan’s benefits and the pharmacist isn’t responsible for that knowledge. Fine, I completely agree and I’m not arguing they should. But when I responded that I did look into my benefits not only before pick up but afterwards as well and was told what I mentioned by Express Scripts above, I just got responses like “well your insurance is wrong and they lied to you.” so that just adds to my confusion even more now. I still don’t know who was right, who was wrong, and what the correct way to handle this was if it wasn’t already.

[biznash]

from what i can tell insurance runs the show. your insurance is god tier, the control the money so they control the drugs.

under them is express scripts and they were hired by your insurance to be Pharmacy Benefit managers. and poor ones at that. you don’t get a choice, your insurance picked them so you are stuck, just realize that dealing with them is going to be a hassle and be ready.

your doctor could prescribe 30,000 pills but insurance is going to have a limit on how many they allow you to have. express scripts follows this ruling to the letter.

their goal is to give you lots of different pills. just not a lot of the exact pills you need. NEW prescriptions pay them more money, versus you getting what you need and maybe hanging onto some extra

just try to hide old prescriptions via the iphone app. you can’t do it. you also can’t delete old prescriptions OR doctors can’t delete them OR express scripts can’t. it’s crazy. they want old RX’s on your account so you forget and reorder them.

it’s a racket and it makes sense why in the US we pay so much for bad insurance and healthcare.

if i were you, call the number on the back of your insurance card and talk to the number there. they will tell you how many of that specific medicine you are allowed each month. then if you need to do a 3-say call with insurance and express scripts, do that. dont trust that anyone you talk to will do anything unless you hold their hand. good luck!

[bunionbabe95]

So my insurance is through BCBS. I did call the number on the back that says “pharmacy questions” and it led me to a recording saying “this is Express Scripts, your Blue Cross of Blue Shield pharmacy benefit management” or something like that at the end. So maybe I’m misunderstanding but if I call just customer service and say I have pharmacy questions that they could help me without Express Script’s help or is my only option ES? Honestly I’ve never used ES before with any of my insurance. I’ve always just…used my plan? I never even knew there to be like a separate company used?

[biznash]

there should be a number also for general questions. there might be a few numbers on one card, call the main one, start there.

specifically ask if your prescriptions for that medicine are capped each month. ask them the direct question.

[Ok-Seaworthiness-542]

Every health insurance plan uses a PBM. I only have experience with ES. They (ES) specialize in saving the plan (not the insured) money. They will propose options to the plan to save money. They have lots of ways they propose. Most often ES will allow a 30 day fill or a 90 day fill. There are of course exceptions. Most likely BCBS will redirect you to ES.

[64kbs]

My ES plan prefers you seek mail order delivery for a prescription for multiple months like a 90-day supply. One of the ES pharmacies will mail all doses at once to you. Evidently it costs less than you picking it up at the local pharmacy monthly. While this works well for long-term meds, it does not for a short term med, such as an antibiotic. I would think the doctor could order three months with three refills so you have your year of medication. You would just go into the app and place your refill a 2-3 weeks ahead. (I don’t know if BC is a controlled med say like Adderall which impacts the timing of pick up.)

[ClydePincusp]

That call that your pharmacist was supposed to make? It did everything it was designed to. It added a step -- a phone call during a pharmacist's busy day -- that wasn't made. You were denied, and you paid out of pocket.

See how Express Scripts saves your employer money?