Thursday, July 5, 2007

What PEIA Won't Pay For...

I don’t really like being on the phone – which is not to say that I dislike it, I just prefer to be face-to-face with people. But, I spent about two hours on the phone Tuesday anyway and another 90 minutes today trying to get my health insurance providers to pay for a drug.

My family is covered through PEIA, the West Virginia Public Employees Insurance Agency. It went like this…

We called our pharmacy and asked them to refill a new anti-smoking drug, Chantix. When I went to pick it up on July 3rd I learned that:

  • July 1st marked the start of a new plan year so I had to pay my deductible on prescriptions again.
  • The co-pay has gone up on brand name drugs from $30 to $50 per month's worth.
  • The insurance company had not reauthorized Chantix.


Sometimes that’s a matter of paperwork. PEIA farms out management of prescription services to a company called Express Scripts. I called them. My wife had already called them once and been told to call a tobacco-free hotline; it was a dead end and, later we learned, it was a contractor who had stopped dealing with West Virginia employees some seven or eight months earlier. Express Scripts was giving out the wrong contact number for “step two” in this process.

During the course of the day Tuesday I spoke to Bob, Linda, and Sherri at Express-Scripts. I learned to get their phone extension out of them before I hung up so that the possibility existed that I might speak with the same person a second time if I had to call them back.

Eventually we figured out that we needed to be talking to the people at the Free & Clear Quit for Life Program. The people at Express-Scripts told me that Free & Clear had the power to reauthorize the medication. The people at Free & Clear didn’t know that Express-Scripts existed. And the people at Free & Clear thought that their job was to pass information along to Rational Drug Therapy at the West Virginia University School of Pharmacy so that they could decide whether to reauthorize the drug. (Rational Drug Therapy, incidentally, doesn’t speak directly with patients.)

Linda, a "patient care advocate" at Express-Scripts, was eventually convinced to read me my benefits. She’d been trying to convince me that we could have a 90 supply of Chantix, but that we had to wait a year before they’d pay for it again (even though the drug’s manufacturer says at their website that if you’ve quit at the end of the 90 day course you should ask your doctor if it would benefit you to take the drug for another 90 days). When she read me the description of benefits it stated that Express-Scripts would pay for a 90 course of the drug three times in the life of a patient and only once per plan year. Her conclusion was that I’d have to wait a year. I pointed out that the plan year had just changed, that it was now a new plan year and that I wanted the 90 days for this plan year to now be authorized. She was confused; she agreed that it was a new plan year, but was skeptical that the drug would be reauthorized.

The last person I spoke to Tuesday was Mary at Free & Clear. God bless Mary. She read me what the contract between PEIA (she’d never heard of Express-Scripts) and Free & Clear. That contract said that Free & Clear wasn’t supposed to authorize the drug if a patient had received the drug within the last 12 month. I told her what Linda had said. Mary “escalated” my case to her supervisor to try and resolve exactly what our benefits were, evidently spent an hour or more in research and in discussions up the chain of her command, and called me back at 8pm at night. Rational Drug Therapy doesn’t take her phone calls after 2:30 in the afternoon, so it was already too late to get the drug reauthorized Tuesday, but Mary said someone from her office would call Rational Drug Therapy today for me, and suggested I call PEIA’s customer service number (which she gave me).

Customer service was closed…

Today I talked to Judy at Free & Clear. For 75 minutes the Free & Clear people worked with us to determine if there was a way to get the prescription reauthorized (covered by our insurance). Eventually Judy decided that the best approach was to call the pharmacy side of Express Scripts and have a conference call with them so that I could be on the line. Kendra there at Express Scripts told us the computer had rejected the authorization. Kendra read the rules about authorizing the drug – a different set of rules (different verbiage) than what Free & Clear had. With Judy from Free & Clear on the phone, Kendra gave us the toll free phone number for the West Virginia Tobacco Quit Line. (The Quit Line told me Tuesday that they couldn’t understand why Express Scripts still gave out their number since PEIA decided seven or eight months ago to do business with Free & Clear instead of them.)

So I have three different versions of what benefits we are supposed to have regarding Chantix:

  • Linda’s (at Express Scripts) version that she read from her computer screen, which says that we can get it three times in our life, but no more than once per plan year. Plan years align with fiscal years.
  • Free & Clear’s version, which says that they’re supposed to ask if you’ve taken the drug in the last year and they’re suppose to say “no” to reauthorizing it if you say “yes” to that question.
  • And Kendra’s (also at Express Script, but on the pharmacist’s side of it) who says that the medicine can be prescribe for 90 days in a 365-day period.


Kendra’s version is open enough to interpretation to be compatible with either the Free & Clear version or Linda’s version.

Bottom line, I don’t really know what our benefits are and if I have our benefits spelled out in writing somewhere, I don’t know about it. I called the PEIA customer service line to ask about it and a recording told me to leave my name and number.

It was an incredible exercise in getting the run around. And PEIA never returned my phone calls, so I guess I'll try them again tomorrow...

3 comments:

Anonymous said...

"What PEIA Won't Pay For..."
Your horror story with your health insurance provider beats any of mine. I sympathize but the story is comical...Has your wife tried hypnosis to stop smoking? Will PEIA pay for it? Maybe you could call them tomorrow if you have a few spare hours.....

Rodrigo said...
This comment has been removed by a blog administrator.
Anonymous said...

What is really a shame here is there are plenty of willing providers right here is the State of WV. We operate a specialty pharmacy in the state which unfortunately mines most of our business from out of state. So much for the "open for business" slogan of WV.