Express Scripts has rejected my four year old son's insulin prescription because they have determined "he doesn't need it". I actually have to go through an APPEALS process involving Jack's DOCTOR to EXPLAIN the need. I am about to lose my mind.
I have enough to get me through an appeals process, but I can't believe I have to do this at all.
Just a warning. This CAN happen.
I cannot believe this but so many strange things have happened when it comes to Diabetes. Are you in the USA?
Do you need to go through mail order? I also had issues with these folks and went back to the walk-in pharmacy. Perhaps that is an option for you? If you have the RX on hand now take it to a pharmacy and see if they will fill it - that way as the appeal is winding it's way through you will not be worried about having enough insulin. Good luck! Barbi
Wow I'm really sorry to hear that! How does a pharmacy have the authority to determine what medication a person needs? I don't care what the RX is for. If a doctor writes it how dare they question it? I use them for my sons insulin also so hearing that scares me a little bit. I'm sorry I can't fix it for you but we are all behind you 100% hoping this ridiculous nonsense gets straightened out soon. Is this the 1st time you've gotten his insulin through them? BTW I do use them through mail order so maybe that makes a difference?
I don't understand. How can a pharmacy say that insulin is not needed by a Type 1 diabetic?
It sounds like the lunatics are running the asylum over there.
Thanks for the support/advice. I am in the USA. I have used them before - all mail order. I have had them fill the prescription before, including this one. All of a sudden I have to prove "medical need" because the pharmacist has determined he doesn't need it. ?!? The supervisor I spoke to said the pharmacist had the final say and that I have no choice but to appeal. I told them - what does it MATTER if I have a prescription from his doctor for it - and apparently they reserve the right to make judgement calls on prescriptions.
I tried all morning to get the prescription transferred to CVS, but no one other than Express Scripts is allowed to fill diabetic prescriptions for my son. (He's on a special plan for people with chronic conditions only, so they can do that.)
The whole thing really blew my mind. Thanks again everyone. I can't even think straight after all this.
P.S. My husband called them last week about a separate issue (their denial of several basic diabetic supplies for my son) and the rep actually said "We own two thirds of the market in the USA and we can do whatever we want." These people and this company are truly horrible.
Sounds like the pharmacist either 1) didn't take note of which type of diabetes he was dealing with, 2) is an idiot, 3) is taking fairly significant recreational drugs, or 4) all of the above. I would go ahead and appeal ASAP, but also, I would get this pharmicist's name and license # and write to Express Scripts stating that the individual in question made a decision that basically would kill your 4-year-old should it not be reversed. Also, report the issue to your state's licensing board. This individual could and should have his license to practice revoked over such a decision.
You might also ask your son's doctor if he'd be willing to write such a letter as well. If it were my son's endo, he'd be going up in FLAMES over this.
We're in California and it's the same for us. Anthony's health insurance covers all regular medical and the special state program covers all things diabetes. So we don't have any options regarding who we get his RX through or even many doctor choices. We go where they tell us we can. It's never been an issue as we get great care but to hear this can happen is scary. Most of us can't afford to pay cash for supplies to avoid insurance drama so what choice do we have but to fight? We actually used his regular insurance at first until he got his pump last month. Now insurance won't touch his diabetes needs. It all goes through the special program. I hope with him being on a pump no pharmacist ever decides insulin isn't necessary for him. Don't they know how much we wish it wasn't needed?!?! Can you contact your case worker for help? Maybe they have some pull with the pharmacy. I know they're not a doctor but maybe they can help speed things up.
I agree 100%. I have never heard of anything so ridiculous as to be beyond comprehension. The system is different in Canada (I am in Montreal) and there are some negatives, but overall, I consider us to be very lucky when it comes to diabetic issues. I have 2 teenagers with Type 1.
Must you stick with this company? Does your insurance insist that you use this company? We have a totally different system in Canada. I can get my kids' supplies, including insulin, from anyone I want. It sounds like they have a real clown running their pharmacy.
Let's be clear: They are not asking you to prove your son needs insulin. They are asking for evidence that you need Novalog specifically because it is not on their formulary anymore. Humalog is on the formulary, and they are expecting Novalog users to switch. About a year ago, WA state insurance did this and our endo was swamped switching people en masse from Novalog to Humalog.
You clarified on another forum that Humalog doesn't work for your son. So, you can't switch, and need to appeal. That is a hassle, and all too common. I had to appeal for a pump because the a1c was "too good". We go through medical necessity processes every 3 months to get enough test strips. It's wasteful and frustrating.
But people should not panic that Express Scripts is denying the need for insulin for Type 1.
It still sounds needlessly bureaucratic. Putting people through these hoops is indefensible.
No this is a different issue. I had called them this morning about the formulary issue (I am fully covered for novolog through the end of the year) and then asked them about my new prescription for this month because I had not received his insulin. That’s when I found out about the rejection and the reason given was he didn’t need it and now I have to appeal. They didn’t even tell me!
Wait, you mean they have been providing Novalog, but this time when you went to refill it, they said you don’t need this particular refill ? Because they think you already have enough?
And I was within my 90 day acceptable window, the prescription is valid, the novolog is covered, my plan supports everything, etc etc. The pharmacist made this random decision and the supervisor wouldn't overrule it. I made them get out his past prescriptions and show that it was filled, that I was within my rights and terms of my plan to fill it, that my son has type 1 diabetes and needs insulin, and they just said "this is what the pharmacist has decided and you have to appeal." And the fact that I wasn't even notified just makes it twice as bad. You're not going to notify a prescription rejection for INSULIN?
I still don't know how to appeal the formulary decision, since they said they haven't set up a process yet and they are going to set up a special one at the beginning of the year and it will take three weeks from the appeal filing to get a decision. I said, how am I supposed to get novolog while it takes you time for the appeal, and they had no answer.
Especially when I can't get insulin NOW for what I am approved for?!?
Look it will get fixed - with a lot of pain and frustration - but wanted to make people aware that it can get this bad and you really need to keep an eye on it. Like we didn't have enough to do already keeping our children alive .....
They just said "he doesn't need it." I have no idea where this decision came from, and they wouldn't let me talk to a pharmacist. They verified I could fill according to my plan, that I had a valid prescription, that it was 3 months, and just said the pharmacist decided "he doesn't need it" and I had to appeal in order to get insulin.
2 weeks ago my durable medical supplier wouldn’t/couldn’t refill our valid prescription for 900 strips for 90 days. They have a dedicated diabetes line so they understand more than the average csr. They told me my doctor had to call the insurance company’s pharmacist to explain why I needed to test 10x a day. I expressed basically what you said - we need these, kid is in puberty; don’t understand how this is my problem, etc. The difference: then rep said, “I have a daughter with type 1. Puberty is so hard. Of course you need the strips. They just need the dr to tell them. They’ll approve it fast.” She even called back in a few minutes to make sure I knew what to tell the dr. I left a message for the medical asst. at the endo’s, and she called back to say it was done and that they’d call in an emergency script if needed. 2 days later the durable medical company called to say the strips had shipped. By the end of it, I thought wow what a waste of a lot of people’s time, but actually everyone I worked with wanted to get me those strips despite the dumb system. In your case, there seems to be 2 problems: a dumb system and a lack of communication. Just reminds me that a few moments of kindness and explanation can make a world of difference. I really hope you get it resolved quickly.
There is definitely a lack of understanding. I am glad you have a dedicated line and definitely found someone who understands. I just have them throwing rules at me, with no discussion and definitely no understanding. I thought a supervisor would fix this right quick - I was very calm the whole time - because there was no way they weren't going to give me insulin, must be some mistake - but when he just deferred to the pharmacist's decision without any discussion or reasoning, and he turned into robot mode, that's when we had to terminate the conversation and now I have no choice but to get my doctor to appeal. I hope it's quick and gets resolved soon. Thanks.
Case worker, hmmm, I'll have to see if I have one. It would be nice if they had patient advocates, at the very least. I have gone to our employer, but it's a very large company and getting someone who can actually help and call on your behalf can be very challenging - and usually futile, unfortunately.
I am so sorry that this is happening to you!!! Thank you for posting this and letting others know this can happen -- my jaw hit the floor when I read your post. Praying for a quick resolution to this problem and that you get through this before you run out of insulin. This is very scary!!