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Old 04-22-2012, 10:50 AM
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Default United Health Care Cutting off Prescriptions

Dear Sir;
I retired last year and United Health Care recently called my wife and informed her that due to the catastrophic nature of one of her medications that they would no longer pay for the said medication. Is this legal? We are looking at ruinous costs every month if something cannot be worked out and will have to move to Mexico where the med is more reasonable- so I would appreciate a response.
Blizzard07
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Old 04-22-2012, 11:26 AM
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Hmm...fix meds or retire in Mexico...seems pretty obvious to me.
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Old 04-22-2012, 11:41 AM
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Originally Posted by blizzard07 View Post
Dear Sir;
I retired last year and United Health Care recently called my wife and informed her that due to the catastrophic nature of one of her medications that they would no longer pay for the said medication. Is this legal? We are looking at ruinous costs every month if something cannot be worked out and will have to move to Mexico where the med is more reasonable- so I would appreciate a response.
Blizzard07
Dear blizzard - There is a bunch going on here. Your health insurance is under a group plan and, therefore, any action against United would be governed by ERISA. in essence, what this means is that you cannot sue for any "extra-contractual" elements. You are entitled to sue for the costs of the drugs and, if you are successful, you can be awarded attorneys' fees. There is no suit for Injury to credit, mental anguish, loss of income, punitive damages, etc.

That's one look at it.

Second, it matters what state you are in as each state varies on how hard they are on the insurer to treat you right. You may wish to consult a local lawyer or your State's insurance commissioner's web site for more guidance here.

Third, there should be an appeal process on their decision., The Health Care act passed by Congress in 2010 guaranteed a review process to persons in your situation but it looks like the five black robes are going to exert their powers over the other four black robes and do away with this entire piece of legislation. Still, there should be some appeal that you must take to preserve your later right to complain.

Fourth, if you can get the medicine in Mexico, why not do that? insurers have been known to spend money flying you to other parts of the world because it is ultimately cheaper for them. Please do not be afraid of other countries' medical care as the propaganda we get hit with is that this countries care is the best over all the rest. In some instances, this is true and in others it is not so, if it is a matter of life and death, please opt to visit another country. Check out: http://medicaltourism.com/


Good Luck!

Steve

Last edited by FELA FELLA; 04-22-2012 at 11:43 AM.
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Old 04-22-2012, 06:00 PM
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Steve;
Thanks-it is sounding increasingly likely that we will become "medical refugees" living in Mexico thanks to this latest railroad contract that gave the insurers these godlike powers of life and death. As I understand it is possible to do mail order, or even walk across the border prescriptions BUT that this is of dubious legality. We cannot risk losing a prescription to legal seizure. We are entering negotiations with the insurers this week and it is possible something can be worked out. It is sounding like the deck is too stacked against us for any possible legal action but I am talking to a lawyer tommorow anyhow. If all this fails? Well I just got back to work on my Rosetta Stone Spanish.
Blizzard07

Last edited by blizzard07; 04-22-2012 at 06:05 PM.
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Old 04-22-2012, 06:15 PM
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That kinda shit stinks, my prayers are with you both.
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Old 04-22-2012, 06:26 PM
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I'm pretty sure that you are not being affected by healthcare changes to ERMA in the new contract if you retired before this year.

It is more likely that you are the victim of the new formulary.

Name of the medication?
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Old 04-22-2012, 07:00 PM
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I'm pretty sure that you are not being affected by healthcare changes to ERMA in the new contract if you retired before this year.

It is more likely that you are the victim of the new formulary.

Name of the medication?
Copaxone. And anyone married to an MS patient take notice (does anyone out there actually read the fine print on these contracts?). Here is another possibility; http://phoenix.about.com/cs/health/a/mexicodrugs.htm http://planetnogales.com/pharmacies.php It sounds that you are legal so long as you can present a prescription if asked on the return trip. The costs are 1/5 of US prices in Canada and about 1/4 in Mexico.
UPDATE; Well we talked to the medicare people and got a new prescription from them. Costs are going to be much higher than with my RR plan-but doable and no we should not have to leave the state (though I am getting increasingly intrigued with Arizona!)

Last edited by blizzard07; 04-23-2012 at 12:34 PM.
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Old 04-24-2012, 12:12 AM
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Copaxone is shown as a Tier 2 drug (middle level co-pay) on the 1-1-12 formulary for active employees. It's also an "Exhibit C - Drugs for Coverage Authorization and Step Therapy Rules" drug under the UTU Agreement/PEB 243 plan.

The new rules still shouldn't affect anyone on ERMA who retired prior to 1-1-12. Not sure how they got you unless it was the way the prescription was written.

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The Coverage Authorization Program consists of traditional prior authorization, smart prior authorization, step therapy and quantity/dose rules which are based on FDA-approved prescribing and safety information, clinical guidelines, and uses that are considered reasonable, safe, and effective. These rules are recommended by an outside, independent organization based on information and data specific to the Railroad membership. Each Therapeutic Drug Category has a rule(s) specific to that category.

Last edited by Xpress; 04-24-2012 at 12:18 AM. Reason: added quote
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Old 04-24-2012, 07:56 AM
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Quote:
Originally Posted by Xpress View Post
Copaxone is shown as a Tier 2 drug (middle level co-pay) on the 1-1-12 formulary for active employees. It's also an "Exhibit C - Drugs for Coverage Authorization and Step Therapy Rules" drug under the UTU Agreement/PEB 243 plan.

The new rules still shouldn't affect anyone on ERMA who retired prior to 1-1-12. Not sure how they got you unless it was the way the prescription was written.
I am not sure how they got us either-but cut us off they did. At 5k a month they would have had plenty of motivation. Beware! ALSO-watch your mailbox as they are playing monkey games trying to get people to respond to something in a ridiculously short period of time or be cut off. So no vacations for retirees anymore! What are people doing that have no experience with the medical system? "Dying" or "Dying broke" I would guess.

Last edited by blizzard07; 04-25-2012 at 02:37 PM.
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Old 04-25-2012, 09:36 AM
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Default Check your med coverage before you retire

Hello;
We recently got stung by MEDCO and it seems that they do not cover catastrophic drugs such as COPAXONE after retirement. More here; United Health Care Cutting off Prescriptions
Blizz

Last edited by blizzard07; 04-25-2012 at 03:44 PM.
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