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Fighting for a Refill

Another Tale of Fighting an HMO

I'm starting this page to document how long it takes to get a prescription refilled through Prescription Solutions, the mail order pharmacy my HMO (Pacificare) contracts with. The first time the scrip was filled, it took three and a half months. Just in case that happens again, I want to have a document of every action I took and conversation that occurred.

1998-05-20. I sent to Prescription Solutions an order for three refills: cromolyn sodium, albuterol sulfate, and Creon 20. Enclosed was a check for $24.00 to cover the $8.00 per scrip co-pay. Along with the check was a short letter stating that Creon is in fact covered by Pacificare, and gave the number of Pacificare's pharmacy. It requested immediate notification as soon as possible if there were any problems.

1998-05-21. Called Pacificare Pharmacy. Representative Stephanie said that Creon 20 wasn't covered, but offered to check with Prescription Solutions. According to them the capsule form is covered. I asked that they approve the scrip in advance and note this in my file with Rx Solutions.

Pacificare's response was that according to my coverage plan, they require me to take the generic or pay the difference. I replied that my doctor did not want me to take the generic. I also pointed out that an exception had been made in December, and asked what the procedure was for making one again. I was told to fax a letter from my doctor to Pacificare requesting an exception to the generic-only policy. I replied that they already had that letter in their files from the last time around. Stephanie said that each new scrip or refill was a different case. When asked if there was a way to get an exception permanently noted in one's file, she replied no. Her response to my request that we talk to her supervisor was that the supervisor had no more power in the matter than she.

Stephanie called Sue from Rx Solutions. Sue affirmed that the generic was currently available.

According to Stephanie, a committee of people from both Pacificare and Rx Solutions creates the list of covered drugs.

She appeared at first not to know who John Handley was, but later said she knew of him.

Duration of phone call: approximately 20 minutes.

I contacted Helen at OHSU and asked that she fax to Stephanie the 1997-12-17 letter requesting Creon instead of the generic.

1998-05-22. Another call to Pacificare. Spoke to Jason. He looked at my file and said that an override had been made in their system, and that the prescription for Creon 20 would be available with only the standard $8.00 co-pay. Yes! I'm not getting my hopes too high, but we'll see.

Duration of phone call: approximately 7 minutes.

1998-05-24. I got a phone message from Stephanie (dated Friday the 22nd) that the override was in place and is permanent.

Some lingering questions:

• Why was the exception made in December?
• How do other people get exceptions?
• What do people who always get exceptions do? Do they have to get an exception every time?

1998-05-27. Ironic note: the original prescriptions for cromolyn and albuterol are now out of date, so I have to get new ones and submit them - another week lost.

1998-06-03. It worked. The Creon 20 arrived. Yea! It pays to take matters into your own hands. Now I just need the cromolyn and albuterol.

My insurance will change in a month or so. Will this situation recur? We'll see.

Important phone numbers

  Pacificare Pharmacy   800 932 3004
  Stephanie's fax       503 533 6011

  Rx Solutions          800 562 6223
  Rx Solutions fax      800 527 0531

  Helen T. @ OHSU       503 494 8023

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