HMO Restricts Pharmacy Access

[DaveJ]

Is it normal for HMO's to restrict access to normal pharmacies that everyone else uses (Walgreen's, CVS, Ocso, even Wal-Mart, etc)???? Being New Year's and all, it was hard to find an open pharmacy this evening, and it turns out that our Humana HMO said my wife MUST go to ONE SINGLE pharmacy which is located inside a nearby hospital, which is closed now (their high paid employees left early BTW -- that's real humanitarian of them), probably closed all day tomorrow.

I am tempted to just pay outright for the medicine she needs, so she can get it in a timely manner, but at the same time, I feel like if I do that THEY WIN!! It is entirely clear insurance companies create these restrictions to healthcare in order to avoid payments.

I have been lucky enough to be healthy most my life. So I'm just wondering, is this the type of BS people go through when they need help???? The insurance companies do ALL THEY CAN to SLEEZE out of their responsibilities?

What does it mater what pharmacy a prescription is filled at, other than to limit access to health care????

[aquart]

1. Ah, the Humana criminals. Still walking free, I see.

[Horse with no Name]

4. Unbelievable, isn't it?

They are slippery.

[rwenos]

2. If it's an emergency

buy the drugs and send the HMO a bill. They're fucks, ain't they?

[DaveJ]

6. That's an good out of the box approach...

I hadn't thought of that. I don't know if it's an emergency, just a very intense earache that comes and goes, which I know must be incredibly painful. She needs antibiotics or something. Her doctor did not prescribe any pain killers, since it seems these days some people tend to abuse them, and a few rotten apples spoil the bunch. She's sleeping now so I'll see how tomorrow goes.

[rwenos]

8. Here's the Logic

HMO's are obligated to treat according to their coverage agreement. If their approved providers are not available, and it's an emergency, common sense dictates you're within your rights to take care of the immediate problem, then make a claim for the money you expended later.

Think of it this way: A Kaiser member who lives in California is in a traffic accident in another state, one where Kaiser does not operate. The member is taken to the nearest hospital with an ER. The hospital, NOT a Kaiser hospital, treats the member.

Kaiser is on the hook for the ER expenses. If the member has to pay anything out of pocket, it's the proper subject of a demand for reimbursement to Kaiser.

HMO coverage would be similar, seems to me. If it goes down that way, TAKE CARE OF THE PROBLEM FIRST. Then write HMO a demand letter, with a copy of the bill and/or credit card invoice. ou might have to sue the HMO to get 'em to pay. If you do, make sure you also make a complaint to your state's insurance regulatory agency. In California, it would be the State Dept. of Managed Care.

I'd be VERY CONCERNED about a spiking fever secondary to an inner ear infection. Take care and do what you need to do to protect your family.

[Warpy]

15. If the drug needs to be started immediately

like an antibiotic for a known bacterial infection, call the HMO and get clearance to use another pharmacy. If they deny it, then get the drug and fight them on it later. The prescribing physician will be on your side.

Sometimes you even win.

Starting an antibiotic early for something like a tooth abscess can prevent complications that waiting 48 hours leaves a patient open to, like blood poisoning, heart valve damage, and brain abscess, complications that can cost the HMO up to a million bucks.

Even bean counters at Humana should know that one.

[Horse with no Name]

3. They make it as hard as they can on you

Sad but true.
I am just now getting all the particulars of my "high dollar" insurance and there are quite a few limitations.
On my vision insurance...get this...it EXCLUDES Walmart from their prices because they say that they already have "everyday low prices".
So--Walmart was able to be on my vision plan without any price guarantees. I thought negotiated prices was one of the advantages of healthcare.
What is the incentive to pay $20 a month per person for vision insurance just for the privilege of paying Walmart's "everyday low prices".:mad:

[LeftCoast]

5. Have you informed the HMO that the one pharmacy they want you to go to is closed?

It seems unreasonable for them to force you to wait days for an Rx, particularly if it is for something crucial such as BP meds, or insulin, etc.

Good luck with those bastards!

[DaveJ]

7. Inform Who???

Almost all the Humana lines are closed. We got through to someone giving the general runaround... saying we can only go to one specific pharmacy in our area, which is closed. That's all they have to say; otherwise, spend the money on an emergency room co-payment, which they know most people can't afford.

Personally, I feel I could cope with having only one pharmacy I could go to, but I'm not the one in excruciating pain. And I know these folks do not care about anything except themselves. It's so frustrating.

I understand it's New Years and most places are going to be closed (some may or may not be open tommorow), but this is more about the fact that they are strategically avoiding making payments by limiting healthcare access. There are other pharmacies within walking distance that Humana will not support!

[thecrow]

9. The HMO's make purchase deals with the Pharma companies

And it's a bitch. I go through the same thing with Kaiser.
Tell them it's an emergency and they will find a place to get the drugs for you...
I hope.
I feel your pain.

[DaveJ]

10. We'll try that tomorrow

The thing is, with our 'preferred' pharmacy closing at 6pm every day, neither one of us can get there in time after work. Humana's clever way of reducing payouts. Plus, even though the pharmacy says they close at 6pm, it appears these pharmacists leave early whenever they feel like it (normal human nature I understand). So if we work we cannot get there at all.

I think my job gives us the option to switch to the PPO version that Humana offers, but I surmise that plan has similar roadblocks to obtaining healthcare.

She seems okay now, just goes through a lot of pain every now and then. It seems she's not fully developed the tolerance to certain ailments that most of us are able to fight as we mature. Anyway, she has had no medical care so far. I guess she has to suffer a bit until it goes away. She's probably used to it. We might as well be cave dwellers.

[China_cat]

11. Read the very fine print on your policy.

You'll see that it says 'valid only until needed'

[thecrow]

16. Kaiser has mail order pharmacies

Order your prescriptions online; receive by US mail.
Costs less and if it's not an emergency, it's very liveable.
Does Humana have this?

[cosmik debris]

12. "(their high paid employees left early BTW..."

High paid employees at a hospital pharmacy???? You've got to be kidding! Right?

[DaveJ]

13. Sorry if I'm mistaken

I was under the impression pharmasists start off at around 80k, but maybe you don't have to be have a degree to work in a pharmacy. You're right, I'm sure they find cheap labor somehow.

[DaveJ]

14. Still, nothing

I guess there was no reason to expect customer service on New Years day. Got through to a rep under their medicaid program though, and she recommended paying for it and sending the claim form in the mail. My wife says she can just wait, live with the pain, and hope the infection does not get worse.

[varkam]

19. Sure, pharmacists make bank. But then there are pharmacy techs...

...who don't make nearly as much.

[DaveJ]

17. Update

Starting Jan 1, by some amazing coincidence, our plan lifted restrictions and started covering all pharmacies that take Humana. Yay! I hate complaining. I can't help think this is improvement is a result of our country starting to move in a more progressive direction.

[LetsThink]

18. The Insurance Cos are Starting to See the Writing.......

Ahhhh-- they've made a BUNDLE and are now realizing people are really ANGRY about how badly they've been behaving toward the most vulnerable folks. Health insurers have really scr....d over SO MANY PEOPLE. SO MANY KIDS.... take the money and run has been the business policy of insurers for YEARS and it's finally looking like they are at the end of that fat road. They're gonna have to actually do honest work to stay in business at all- And, yes! Vocal progressives have made a HUGE difference- moved the center of that issue to a more reasonable spot for those of use who need health care.... ummmm, isn't that, like, EVERYONE?

VOTE CLINTON!!! She's the ONLY CANDIDATE with a PLAN THAT ENSURES EVERYONE HAS BOTH HEALTH AND DENTAL CARE-- ALL AMERICANS. Some say they do..... her plan delivers.

Signed- mom to a 10 yr-old special needs child, who has been twice kicked off plans because of his expensive health care needs......