I'm PISSED!!..need a little help from the smart folks here...

[Ms. Toad]

73. First - I'd follow up with the person from UHC who posted here.

One of the things I would ask for is

(1) A copy of the prescription drug coverage policy which explains (generally) what you are entitled to
(2) A copy (or link) to the current formulary
(3) A clear explanation of exceptions to the formulary (step therapies on the formulary are easy to get approval for; drugs off formulary are harder - but generally not impossible; there may be other categories as well)
(4) A copy (or link) to the policy and forms required for pre-approval of medication or step therapy

My first step is to get know my policy better than any customer service rep who may answer the phone. That way when someone gives you bad information you can call it to their attention immediately, rather than researching it later. If they can't resolve it, you can immediately ask to speak with a supervisor. They often (not always) know more than the average customer service rep. Take names and notes. Document everything. If they can't resolve it immediately, get a specific commitment as to what the next step will be, who will take it, when it should be done, and how you will know it is done.

If that doesn't resolve matters, and the prescription coverage is included in your insurance but handled by a different corporation, get on the phone with your insurance company. Your contract is with them. They won't like getting calls about drugs, and you may have to ask to speak with a supervisor there, but ultimately if the entity they choose to farm you out to for drugs isn't behaving, they need to make it right. Again - document.

As noted by others, try the rep through your company (or the insurance agent if no HR rep). I used mine for connections - but the reality is that I knew more about my policy and the law than she did. But there are times you may need their connections (and you may be lucky and they may be really good).

If all else fails, appeal. I hate appeals. My personal philosophy is to make them follow their own procedures without appealing and save the appeal if I am technically out of compliance with the policy (like, for example, when Kaiser imposed both a period and a # of visits on a specialist who was previously subject to unlimited visits in that same time period and neither my doctor or I noticed we were within the period, but beyond the # of visits). They will tell you to appeal everything. Even when it is their screw-up. I don't - so I don't know whether that works. I do know that I have never lost a battle I chose to fight (and in 2 decades can only remember two battles I decided weren't worth it).

Good luck. It is, at least, satisfying when you get to the point where you routinely win.