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WARNING-2014 Prescription Exclusion List for ALL Express Scripts Subscribers

Discussion in 'Parents of Children with Type 1' started by moco89, Nov 1, 2013.

  1. moco89

    moco89 Approved members

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    I wanted to point out that you can appeal bills/billing too. I cannot help much on that aspect, as I have no experience appealing bills, although I pay for my healthcare. I would avoid killing two birds with one stone by trying to get approval for insulin/test strips AND decent billing, as this is too risky and high stakes. Appeal for billing AFTER you get approved, even if it hits you in the pocketbook. You can always request in the billing appeal to get a reimbursement check, one way or another, for previous prescription fillings that occurred while the appeal process occurred. Just expect for that to be a huge hassle, as Express Scripts is extremely incompetent.

    Express Scripts needs to get screwed by competitors. There is no way that your pharmacy benefit is "competitive", or your benefits for that matter, when you only have one option for rapid-acting insulin and one choice of a major brand for test strips. Amazon is actually entering this business, supposedly.
     
    Last edited: Nov 1, 2013
  2. MomofSweetOne

    MomofSweetOne Approved members

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    I think the bottom line is money, not American products, because the Aviva test strips advertise that they're "Born in the U.S.A."
     
  3. dianas

    dianas Approved members

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    Regarding the comment on Retail....A lot of times Express Scripts is not just the mail order pharmacy they are also your insurance plan's pharmacy benefits manager so the exclusions apply to any pharmacy used under your plan and you need to go through the appeals/over ride process.
     
  4. tannafis

    tannafis New Member

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    I received a letter this week about them not covering my sons Accu-chek test strips. I called them and filed a complaint but was basically told by their customer service rep it probably wouldn't help. I don't mind switching but it's just a hassle.

    We are currently looking into the Omnipod and I was quite surprised it would not cover the strips for that meter.

    In the letter that I received, they also sent another paper which said I could get one free meter to accommodate us having to switch.
     
  5. sincity2003

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    If you are going with OmniPod, ask your medical insurance about getting the Freestyle test strips through your DME coverage (Durable Medical Equipment). It's the same coverage that covers your pump. We are saving over $200 every 90 days getting them this way and I don't have to fight with Express Scripts now to get them covered.
     
  6. Sarah Maddie's Mom

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  7. ecs1516

    ecs1516 Approved members

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    I remembered hearing our endo office tell us that insurance was going to go to one brand of strips and overrides would not help. This must have been it.
    I could not believe when I heard that but after reading this it must be true.
     
  8. redheadmom

    redheadmom Approved members

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    According to this article, Insulet will at some point be selling a new Omnipod pdm that uses the verio test strips. Hope it happens soon, because then we would not have to use a separate meter with our covered One Touch strips.

    http://diatribe.us/issues/46/new-now-next/5
     
  9. caspi

    caspi Approved members

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    If the roll out of the last "new" PDM is any example, I wouldn't hold your breath of this happening anytime soon. Hopefully I am wrong. ;)
     
  10. missmakaliasmomma

    missmakaliasmomma Approved members

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    Apidra had to be overwritten by the dr to be covered by my insurance. The insurance likes to only cover Humalog. I'm almost positive that Apidra is unheard of by most of the patients in my daughter's endo practice. My only guess is that it's newer and that's the reason her doctor doesn't "throw it out there" to her patients.

    It's been great for us and I don't want to think about what would happen if the insurance didn't cover it at all anymore. We don't use express scripts though.
     
  11. moco89

    moco89 Approved members

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    Thank you for making this recommendation.
     
  12. MHoskins2179

    MHoskins2179 Approved members

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    It seems to me that the first step would be to contact one's insurance company (in Jan 2014), to determine whether a particular brand of strip is in fact "covered" - regardless of what Express Scripts says and how it loosely uses that word. Then, if a doctor's pre-authorization or override is needed, there's a process that will be in place - much like there is now when it comes to "preferred" and "non-preferred" brands on a plan's formulary.
     
  13. Megnyc

    Megnyc Approved members

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    Express scripts is the insurance at least in my case. I have totally separate medical and prescription insurance policies. Aetna covers medical and express scripts covers prescription. In terms of DME and strips, I can go through either policy. Insulin has to go through express scripts.
     
  14. moco89

    moco89 Approved members

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    I have the exact same insurances as you, but of course with a different policy. Diabetes-wise, I am in the same situation as you.
     
  15. moco89

    moco89 Approved members

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    These individuals need to be stocking up if they do plan on trying to overturn the decision.

    I would almost bet my life on it that it requires an appeal, and that a "prior authorization - override" is not going to work with an excluded medications. I deal with insurance all the time, unfortunately.

    You have no idea how incompetence of Express Scripts. The customer service representative training is essentially non-existent. They have no idea what is going on. You will get a completely different response for each issue when you ask each representative.
     
    Last edited: Nov 4, 2013
  16. sincity2003

    sincity2003 Approved members

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    Yep, we are stocking up on Novolog...but we were going to before this decision, because DS has been on Humalog before and we didn't notice any difference in his care. We are stocking up because we have a $2500 deductible to meet before any medical/medicines are covered, so I have all our prescriptions/pump supplies set to renew on 12/24 or 12/31 for 3 month supplies, which gives me 3 months to save up for the next ones.
    But yes, I agree, either stock up so you have time to appeal, or again, check your DME coverage for strip/pump supplies.
     
  17. virgo39

    virgo39 Approved members

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    Express Scripts is not, as I understand it, an insurance company. It manages pharmacy benefits for insurers.
     
  18. Megnyc

    Megnyc Approved members

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    No, it is not technically an insurance company. However, at least in my situation the employer (who covers prescription costs) is self-insured. Thus, there is no actual insurance company to contact as was suggested in the post I was replying to.
     
  19. sincity2003

    sincity2003 Approved members

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    This is our situation as well. I think most large employers are self-insured and this is a common set up they have.
     
  20. denise3099

    denise3099 Approved members

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    Time to start hoarding meds!!! Seriously, you never know what other changes could sneak up on you in the new year. If your dex transmitter and/or receiver is out of warrenty, contact foundation care about getting another. I just called and am getting a new transmitter and sensors. Get whatever you can trhough foundation care though rather than dex. Stock up on pods through express scripts. Stock up on novo and strips, even alcohol pads. I'm getting insulin, strips, pods, sensors and a new dex transmitter before the year end. It's like preparing for a hurricane--you just don't know wht is going to be available or how much it will cost.
     

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