Did you ever wonder how insurances come up with some of the formulary/dosing guidelines they use?
#1. Insurance rejects #30 Prevacid 30mg for a 30 day supply because they only allow for a max of a 21 day supply. When we reprocess this for 21 capsules, they reject the claim because "minimum day supply of 28 not met"...Now I think they're just playing with us.
2. Insurance kicks back a claim on Prenatal Vitamins with the DUR that says "Warning-carefully evaluate use in pregnancy"...So they're only useful before and after?
3. Maximum daily dose of Prozac 40mg capsules = 0.75 capsule per day? I called the insurance lady and she proceeded to ask if I had called the doctor to notify him of the high dose. High dose? I told the lady the doctor would laugh at me if I called and said the patient's insurance requires her to take only 3/4 of a capsule per day...I understand pill-splitting in some cases, but, really?
4. Insurance required insulin and pen needles be purchased together. Her Lantus and Novolog Pens each lasted 48 and 50 days, irrespectively. They would only allow her to get 100 needles at a time because she only used 3 shots a day, combined. Her needles were due every 33 days. We called and asked the insurance how we could bill them on the same day since the insulins would be 2 weeks too soon. They didn't know. Said we would have to call each time for an override. Right. Your rules are stupid so I have to do more work. Fantastic.
5. Mail order overrides--this is a post in itself, but...what about an unbreakable package? We call for the override to be told we have to reprocess for a 14 day supply and we have to change the dispensed quantity. Um, how do I take 16 inhalations out of a Spiriva or 32 from an Advair? Why should I have to even call for this? Give me override code for "unit-of-use" item. They have us running around like crazy fools. I think they secretly post cameras in our stores and watch us like some billionaires' pet reality show-like Rat Race where they're betting on whether or not we're going to lose it. Why not? They already record our calls "for convenience and training purposes".
We let the insurances make the rules for so long they are completely in charge. While they complain about tough times and how rising healthcare costs must be shouldered by more employers and employees, they continue to report record profits. Why are we paying more and more and getting less and less? Yesterday's news reported some states are seeing insurance costs rising by double-digits, some as high as 26%. For what? It's like big oil. You can't tell me rising costs are a burden to be shouldered by everyone else then report record profits as a company year after year.