I’m trying to be all healthy and active and whatnot

I Read A Lot of Internets

Pondering

If anyone reading this works for an insurance company, could you answer a question for me? I have an HMO and am only allowed to get one refill of birth control a month. Why is that? Is it simply a cost issue or is there some behavioral prediction going on there? Like, since I’m lower income, do they think I’ll take the extra refills and sell them on the street?

“Hey, man, I got that NuvaRing. Got that NuvaRing, son. Need a patch? Need a patch? Need a patch? This new Seasonale will get you not-pregnant as SHIT. AND it’s good for your skin.”

I’m not sure why, in my imagination, black market birth control customers are male, but there you have it.

I could call Health America and ask them myself but something about calling an insurance company strikes fear into my heart.

Also, ewww…

9 comments to Pondering

  • Amber

    I remember that ad. Disgusting.

    If you do get an explanation for the birth control limit, I’d be curious to see the rationale. My suspicion, however, is simply that HMOs are run by conservative misogynists who would rather let a man get a year’s supply of Viagra no questions asked than aid women in the pursuit of reproductive freedom and population control. You know, when we’re not knocked up and chasing kids around, we are very threatening to people like the douchebags that run most HMOs, so it stands to reason they’d want to do their part to keep us barefoot and pregnant.

    I am so disgusted with the healthcare industry in this country (health care, IMO, should not even be an industry for profit, but I’ll save that socialist rant for some other time), because those that run it are not in the least bit concerned with public health. It’s amazing to me the number of preventative care and life-saving procedures that are turned down in claims.

    I am pretty sure there is a special hell for most health insurance executives.

  • alaina

    I have that same question. When I was under my mom’s insurance (upmc) I could get like, 3 months of pills at one time, but under my new one, (highmark/medco whatever) I can only get one at a time, and if I call the prescription in too early, it will NOT get filled. nonsense!

  • Ben

    In most cases a lot of HMO/Insurance companies along with your PBM(folks who handle all your Rx stuff in most cases) Sit down once a year with a panel of doctors and set a list of what’s a reasonable usage amount of a medication and what you can and cant do with them. Basically they set the limits that your plan has when it is generated adheres to in all cases dealing with Rx’s. To get an exact reason as to why you would want to call the HMO itself and not the PBM. The PBM would not really have an answer to give as they just manage the plans that handle all of your Rx stuff. In most cases that I have found working with a PBM (Prescription benefits manager)The setting of a limit its basically just made up by the insurance company itself as whatever they deem reasonable usage of a medication. If you would be looking to just have more on hand to be safe look into your plans Vacation stipulations that’s one type of an override to a PBM’s system that would let a member get another months worth of their Rx if the script they gave to the pharmacist had multiple refills to it.

  • alison

    i think it depends on your insurance company. upmc also let me get 3 months at a time. blue shield makes me go to the pharmacy every month. a pack got flown to pittsburgh without me once (always put your pills in carryon!) and walgreens was allowed to give me another one (maybe under vacation rules?), but that was the most i’ve ever been able to get here.

    at one point i had a scheme to get 3 birth control prescriptions (for the same pills) from 3 different places and see if the insurance company would catch it. it failed early on because the reality of 3 pelvic exams in a month was too hard to face.

  • Eems

    With CMU’s HealthAmerica HMO coverage, you can get three month of BC at once. You just have to A. have your DR write a 90 day script and B. Use Pharmacare, the mail order pharmacy. It sounds like a HUGE pain in ass but really it’s not. Pharmacare’s turnaround time is like, 3 days.

  • Amber, I like your theory.

    holy crap, Eems, thanks so much for the tip!

  • couple things…
    1) it’s not just “lower income” folks who have this problem. my dad worked in a union for 30+ years, and his insurance prevented multiple-month prescriptions for my mom (who has MS…so it’s not just for birth control either…).

    my dad just retired, and they just left to go stay with my uncle in the ATL for a couple weeks, and they basically had to jump through all kinds of hoops to get her prescriptions filled early. last week, i actually heard my dad say, “I’m 58 fucking years old, and you’re telling me i basically need a note from mom for this? you’ve got to be kidding…”

    2) in case you missed it, someone left a nifty little explanitory paragraph over at LJ.

  • Ben

    Pharmacare is the PBM that i use to work for. if you have your dr write a 90 day supply with 3 refills and you fill it with the mail service the script will carry over for 1 year for you so you dont have to keep going back to your dr every 90 days for a new script. You save money going with the mail service as well it was some deal that you basically pay for 2 30 day supplies and the 3rd 30 supply is free or something like that. I dont remeber exactly how it worked but I rembered telling lots of folks about it and they loved that idea.

  • juli

    in working for a pharmacy and spending half of my 50 hour work week on the phone with insurance companies i have learned this. if you have any sort of goverment funded insurance a 90 day supply is no big thing, but any insurance that you actually get through a job or pay for out of pocket you get completely screwed. the only way for you to get a 3 month supply is to suck it up and go mail order, which rarly comes in on time or go with a pill such as seaonale due to the fact that 1 fill is for 3 months with that pill. insurance companies totally suck and they give pharmacies a really hard time about the stupidest stuff. i once fought on behalf of a customer for 2 hours in order to get a cheap antibiotic they desperatly needed. the reason you will also save money with mail order is because your insurance company charges you a convience fee for going to say the lovely folks at rite aid to get your scripts pronto

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