Prescription Plan Spells Predicament

It happens every year. My husband’s company starts the year with either a new health insurance plan or a new prescription plan. This year, it was a new prescription plan.

One of the many things I do as a Professional Geriatric Care Manager includes advocating for our clients’ needs by accessing their insurance when there is a problem. But, this time, it got very personal. This time, it was about me!

I am still stunned by my experience and thought it was best to share how events unfolded when I tried to obtain my medication. It is a lesson to all of us and one most of us already know too well. Here is what happened:

January 17th — I sent my new drug information form to my primary care physician to keep in my file for the future

February 10th — I called my primary physician’s office to order 5 prescriptions (I have high blood pressure, Asthma, and Osteopenia)

February 12th — I left for a vacation out of the country

February 21st — Upon returning home from vacation, I received a message from the doctor’s office. They were unable to identify my insurance provider and yet previously I provided them with the information. My prescriptions were ordered through Express Scripts the following day.

February 28th — Contacted the insurance company because I still had not received my medication. Apparently the Asthma medication was not on the approved list. But, this denial was overturned and I expected to receive the medication in 5 – 10 business days.

March 4th — Still no medications. Called the insurance company again. Now the medication for Osteoporosis was not approved and needed to be appealed by the doctor. I requested passionately that I needed my other medication. They promised to send it in 3 – 5 business days

March 7th — Another call to the doctor’s office requesting the appeal for the declined medication. They said that they would handle this appeal immediately. I still did not receive all other medication. I called the insurance company to ask “why?” They apologized and stated all would be shipped in 3 – 5 business days, but because of the delay they would send it overnight at their expense. Total time equals another week. They also said that I was approved for my Osteoporosis medication. Also, they would approve 3 of the medications to be picked up at my local pharmacy rather than by mail for my convenience.

March 8th — Called the pharmacy to pick up the medications. Now only one of them was not approved. I called the insurance company to find out what happened. They apologized and said that they would fix this problem. I called the pharmacy back and was told that it was approved.

Here’s What I Learned

Based upon my personal experience, I have thought the insurance and health care system challenges our seniors face. How many of them could sustain this quest for better senior care?

Each company has their own formulary or list of “approved” medications to save money for the company and possibly the consumer. When someone’s insurance is changed, the medication that has been sustaining them is up for grabs. In my case, neither my doctor nor I was informed until I reacted to the fact that nothing came in the mail. My doctor did not know to appeal because no one told her that an appeal was necessary.

Tips For Facing Prescription Providers and Living To Tell About It

When helping a senior or yourself, here is what I have learned:

  • Understand your company’s formulary
  • Anticipate problems when a drug you are using is not on the list
  • Develop a deep and lasting relationship with those who work in your primary care physician’s office.  Be on the best of terms.  You will need their support.
  • Be proactive and never take anything for granted
  • Be a “gnat”.  Never let go of the goal at hand
  • Use any leverage that you may have to achieve your goal.  For example, I will discuss my situation with my husband’s Human Resource Department.  Also, writing this blog is helpful in working through my experience.
  • Ask for a supervisor when the person you are speaking with is not helping
  • Understand this:  You can not change the system, but you can learn to work within it.

Our seniors face many challenges. Compliance with medication management is a key component in sustaining people in their homes. When they have challenges in receiving the medications necessary to manage chronic and potentially dangerous conditions, we must advocate on their behalf. Complete Care Strategies fights this “good fight” every day. We’re here to help you too!


About the Author

Beverly Bernstein Joie is the founder and president of Complete Care Strategies, a senior care management company serving Philadelphia and its surrounding communities. A Certified Aging Life Care Manager with more than 20 years of experience, Beverly has worked in senior care since 1994, both in assisted living communities and in private practice. She is a member of the Aging Life Care Association and was a former president of the Philadelphia Chapter.

Complete Care Strategies consists of care managers, specialized human service professionals, who advocate and direct the care of seniors and others facing ongoing health challenges. Working with families, its expertise provides the answers at a time of uncertainty. Along with its licensed home care division, it can help clients safely remain at home under the watchful eye of skilled professionals. Families are afforded an integrated model of care that, with guidance and advocacy, lead them to the actions and decisions that ensure quality care and an optimal life for those they love