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  • 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

  • #2
    Hmm...fix meds or retire in Mexico...seems pretty obvious to me.

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    • #3
      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, 11:43 AM.
      Steve Gordon
      Gordon, Elias & Seely, L.L.P.
      FELA Lawyer
      FELA Lawyer Blog
      Serving Injured Railroad Employees Nationwide
      Call for a FELA Lawyer 24/7/365
      800-773-6770

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      • #4
        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, 06:05 PM.

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        • #5
          That kinda shit stinks, my prayers are with you both.

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          • #6
            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?
            ---

            Comment


            • #7
              Originally posted by Xpress View Post
              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, 12:34 PM.

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              • #8
                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.

                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, 12:18 AM. Reason: added quote
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                • #9
                  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, 02:37 PM.

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                  • #10
                    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; http://www.yardlimits.com/forums/ask...criptions.html
                    Blizz
                    Last edited by blizzard07; 04-25-2012, 03:44 PM.

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                    • #11
                      Were you able to follow up with Medco & see if there is an alternative forumulary that they will cover? Is there no way to get Medco & the doctor on the horn together to come up with something?
                      Standard lengthy disclaimer / warning / terms of use: All postings by "NSRLink" are fictional, public information, for entertainment purposes only, should never be taken seriously, and in no way should be construed to represent the positions, views, ideas, or thoughts of any railroad carrier, person, entity, organization, or otherwise. By reading anything posted or associated with the user ID, "NSRLink," any entity agrees they shall not be offended, harmed, sad, defamed, inflamed, upset, mad, harassed, have their feelings hurt, or similar. Parties or entities not agreeable to these "terms of use" are hereby required to block this profile "NSRLink" and agree to not read or view posts so they will no longer be offended, harmed, sad, defamed, inflamed, upset, mad, harassed, have their feelings hurt, or similar in any manner, and may do so via UserCP "Edit ignore List" & adding "NSRLink" to the list. Thank you & good day to you.

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                      • #12
                        Originally posted by nsrlink View Post
                        Were you able to follow up with Medco & see if there is an alternative forumulary that they will cover? Is there no way to get Medco & the doctor on the horn together to come up with something?
                        No. We are having to go through some Medicare programs and are totally cut off from Medco on this one. Such lawyers as I have talked to seem to think that the deck is stacked against us as "YOU signed that contract!" EVEN IF we get set up with a medicare program that will cover anti MS drugs at reasonable cost I plan on selling everything and moving close to the Mexican border as the Ryan people are talking about cutting medicare too.
                        "Once burned forever cautious."
                        Last edited by blizzard07; 04-25-2012, 10:38 AM.

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                        • #13
                          Why do you keep referring to Medicare? I thought that you were referring to UHC and the negotiated healthcare benefits commonly known as ERMA or GA-46000.

                          Now, it sounds like you may be under Part D Medicare (your choice) and the lawyers are probably correct.
                          ---

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                          • #14
                            Originally posted by Xpress View Post
                            Why do you keep referring to Medicare? I thought that you were referring to UHC and the negotiated healthcare benefits commonly known as ERMA or GA-46000.

                            Now, it sounds like you may be under Part D Medicare (your choice) and the lawyers are probably correct.
                            That would seem to be the case-the problem being that under medicare we pay full price for 3 mos and 33% after that on a 5k a month med-and I believe it resets every year. SO! There are some programs to help with costs out there we are waiting to hear on. EVEN IF all this pans out and we are not paying through the nose-I am pulling up stakes and running South and close to the border farmacias...just in case. ANYBODY ELSE FINDING THEMSELVES in this situation-contact your Pharmacy and ask about assistance programs (the drug manufacturers have quite a few) and be prepared for a lot of phone calls and paperwork. And you might think about not retiring if you are looking at about 30k a year on one med like I am.
                            Last edited by blizzard07; 04-25-2012, 04:38 PM.

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                            • #15
                              I take Copaxone myself, and it is spendy...I mean it would wipe out most if not all of a retirees money. I have no trouble getting it, and my copay is as it would be with other non generics. But to get it paid, I had to get a letter from my doc to the Hospital Association that it was necessary for me to have it. Once they got that, I was approved. But since it is not automatically on the formulary I have to get a new waiver number if and when I change pharmacies. And my HA has put me on mail order, and it so happens that the mail order pharmacy is owned by the third party drug company that supplies coverage for us. Go figure, but they are right on the money every month calling me to see when to send more meds. Copaxone is pretty mainstream as MS meds go, and it's efficacy is legend...heck I am still working!!!!!!!!!...............So you ought to be able to get something worked out. Here's hoping. And if there's no dice, before fleeing to Mexico...call www.sharedsolutions.com . They can work with your insurance and even get you some discounts and even free Copaxone if worst comes to worst.
                              sigpic ΜΟΛΩΝ ΛΑΒΕ "Come and get them" Leonidas I to Xerxes, at Battle of Thermopylae

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