I think you should get a lawyer , this is ridiculous. I have express scripts also and got a letter a month ago telling me 1. we have to switch over to Humalog and 2. they will only approve one touch meter and strips , no other. My daughter is on omnipod pump which the pump is also a meter that only uses Freestyle strips. so called my job and told them is was unacceptable and made a fuss and they grandfathered us in. Cant imagine that they tell all their diabetics that they now have a choice of only 1 meter to use, and is Novalog and Humalog that much difference in price?
Considering all that... I would contact the ADA and ask for them to help you lawyer up. This is malpractice on the part of the pharmacist, full stop. Pharmacists do not have the authority to overrule a physician's judgment when it comes to what medication a patient needs UNLESS there is an obvious contraindication for that medication in the patient that the doctor has overlooked. Which there is not, quite clearly... but even if there were, the pharmacist is SUPPOSED to notify the physician of the problem so the physician can authorize an alternative. For a pharmacist to simply say "he doesn't need it" when we're talking about a condition that is life-or-death without the medication is lawsuit-worthy. If nothing else, this pharmacist needs to be reprimanded; personally I wouldn't stop until he had his license revoked.
I hear you. I can't believe they didn't notify ANYBODY - they offered to "restart it" because it had been rejected with no communication. And I can't believe that this is being left as a judgment call by the pharmacist. I kept thinking, has the world gone mad?!?
My husband is writing a letter to the FTC about how the massive merger between Express Scripts and Medco has caused very damaging outcomes for patients, despite all their claims otherwise. The FTC barely cleared the merger and they need to know how it is affecting real people in the aftermath.
I will also contact the ADA and JDRF. Express Scripts is making things unbelievably hard for diabetics. I have this case to quote which is mind boggling, plus the new formulary changes - 25% of which are for diabetics, and eliminates most treatments for diabetes - just makes this completely reprehensible towards the diabetes community. As if we didn't pay enough money and suffer enough with this crazy disease, and as if they weren't making enough money off of us. Something needs to be done.
Hi all,
The folks at Express Scripts noticed this conversation and contacted me (I'm the TuDiabetes Community Manager). They invite Jack's Mom, and anyone else who has concerns about their services, to contact them at ExpressRxHelp@express-scripts.com
I hope they can rectify your situation, Jack's Mom!
Very interesting to see that people at these companies monitor the "word on the street." I hope that kicking up a storm over this ridiculous situation will bring changes to their system, or at the very least, resolve the situation for Jack and his mom. Good luck!
Here's what I sent them:
I’m not an Express Scripts customer, but I am curious what kind of service I could expect from Express Scripts should I ever become a customer. When I make decisions about which health plan to choose, I would like to know what to expect. I know that Express Scripts promises (on your website) to help reduce “Unintentionally poor decisions by patients, caregivers and providers [that] compromise health and drive more than 400 billion dollars of annual pharmacy-related waste” and to “increase member satisfaction.” I’m mostly wondering about the latter.
I have a child with Type 1 diabetes who uses an insulin pump with an integrated blood glucose meter and a continuous glucose meter. That means I regularly order transmitters, sensors, test strips, Omnipods, and vials of Novalog plus I order Lantus pens and Novalog cartridges as backup in case of pump failure. Novalog cartridges work with pens that deliver .5 unit doses, which help provide accurate doses. My daughter is in puberty. This means her insulin doses change very quickly, and there are many prescription changes. It also means she needs to test more frequently (now, 10 x /day). This can mean frequent medical necessity paperwork. Her pump uses Freestyle strips only, and if those are off formulary, then that’s more medical necessity paperwork. I get insulin at my local pharmacy, and other supplies through the mail. My insurance covers any brand of insulin 100% without a co-pay.
If I were to use Express Scripts, must I use only mail order? What do you do if someone needs more insulin right away? Mail order sure is convenient for some things, but I am not sure that expensive, time and temperature sensitive medication is among them. Plus, if there is some problem filling a prescription for insulin, my local pharmacist calls me personally. He’s not going to just hope we make it through the weekend.
Will I speak with someone who specializes in diabetes when I call? As it is now, I reorder supplies by calling someone who specializes in diabetes. When I recently called and said, “She’s in puberty, and needs 10 strips a day.”, the person answered, “My daughter has Type 1, and I understand you need those strips. Here’s what to do.” They do not say, “Your insurance covers 4 strips a day, so you’ll have to appeal.” When my daughter dropped her pump in a fountain and I called to replace it, the rep asked if I had enough needles and long-acting insulin. That’s not her job, but she knew enough to know that she’s not just entering an order, she’s assisting with an urgent matter. I can’t see any evidence of a diabetes team with Express Scripts. Do you have one or would I be talking to the same person who fills orders for Crestor and Viagra?
If I need strips right away, but there is some delay getting the medical necessity paperwork done, can you overnight me a few boxes of strips without charge while it’s getting resolved? My current company does this.
If we are going through a process of pre-authorization, medical necessity, or appeals, does Express Scripts notify me of the expected timeline and where we are in the process? Per company policy, a live person calls from my current company (doctors’ office, insurance company, and durable medical equipment company) to say, “We have your appeal. By law, we must get back to you in 30 days, but I’ve just given it to the team, and you can expect an answer much sooner” or ‘We just wanted to let you know that your insurance approved the 900 strips and they shipped today.” Does Express Scripts do this, or is it up to me to call you to find out?
In 2014, if I were an Express Scripts member, and I needed to continue using Novalog, what would I need to do? If I have to provide evidence of medical necessity or appeal, how long would that take? How would I get my insulin while that process was going on? Would I have to repeat that process for each prescription?
So – With my current plan, all brands of insulin are covered 100%. I reorder by calling a team of folks who specialize in diabetes. I get regular phone calls with updates when an order requires some additional paperwork. If there is something that slows an order down, I can have a prescription called in to a local pharmacy and pick it up immediately, or get it sent to me overnight at no charge. If I had the option to changing to a plan that contracts with Express Scripts, would there be some benefit to me personally?
I appreciate the time it takes to respond to these questions. I think it’s important. It will help me make decisions about health benefits in the future.
I will try and let you know! Thanks for the message.
You are AWESOME Wren! Thank you! This matters, and I am glad you took the time to let them know the concerns we have as diabetic parents, families, patients, and kids.
UPDATE - STATUS. My endo's office finally got a hold of someone at Express Scripts today, made sure they approved my prescription TODAY, and said it would ship TODAY. My endo's office said they will call back later today to make sure they do it as well. I did not use the email address because I was hoping the process I already started with my endo would be the fastest way to fix it, and they got it done.
WHAT HAPPENED. This is what I found out. I have prescriptions for Novolog in a vial and a pen fill. They had sent out my prescription for vials previously, and when I submitted and checked on my prescription for pen fills they said he "didn't need it" because apparently the PHARMACIST had decided I had enough insulin from the vials. Wha?!? Note I have had vials and pen fills filled previously many times with no problem, I was in compliance with my plan and all rules, had a valid prescription, and was within my window to order.
My husband and I have to work full time ever since my son was diagnosed as a baby, and we have several lay people throughout the day that take care of him. We use the vials at home between myself and his father, but when my son needs insulin from a syringe by far the safest way for him to get insulin is via a NovoJr pen. His standard dose is only a half unit, and the pen allows you to dose from 0.5 units up in half units. Any errors like mistakenly giving one unit or getting a bubble in that teeny tiny amount drastically affects his blood sugars. Especially in a 30 pound four year old. And we have to be even more careful in a small child with a rapidly growing brain because seizures can cause much more brain damage in a child under 6.
Not that I have to explain that. The prescription should have been enough.
Anyway, problem solved, as painfully as possible. Thank you to everyone for your help and support.
I am so glad everything is fixed! Thank you Mr Pharmacist who has no idea what it’s like to have a diabetic child for making a decision based on the black and white evidence and refusing to look at the gray areas of having not just a T1 child but a very young T1 child. Please allow this incident to teach the person at the desk making uninformed decisions to learn to ask why in the future instead of scaring the heck out of mom! May they also learn that T1 is mostly gray areas and black and white decisions almost never apply.
Thanks Jennifer, big hug. I had to laugh when you said "Mr Pharmacist who has no idea ..." Probably the first real laugh I have had in three days.
So Express Scripts replied to me saying that they have people who understand diabetes for just this situation:
“Our specialist pharmacists and nurses provide personalized attention to patients diagnosed with chronic and complex conditions, including diabetes. We have a deep understanding of the disease state and work directly with patients to optimize the health choices they make. For example, our specialist pharmacists in the Diabetes Therapeutic Resource Center counsel patients on new therapies, the risk of side effects or potential drug interactions and the importance of adhering to a treatment plan”
Very little about this seems relevant for people with type 1, so I asked and they said this service is in fact in place for people with Type 1.
Do you have any reason to think the people who made these decisions have knowledge of diabetes (any kind) or Type 1 specifically? I personally would like to know so I can both make good choices about my own benefits and make sure my employer is aware if exactly what services different companies provide.
I can not recommend Express Scripts currently under any circumstance. If they would just fill my prescriptions without hassle, they would make a ton of money, get their $10K+ from me every year, and I would not complain. Here are a few examples of interactions. Note all these incidents are in relation to a baby with diabetes, and shows a distinct lack of empathy and understanding of diabetes.
1. When ES bought Medco, they tried to ship insulin via two day packages (not next day as previously handled) - all of which showed up warm and against the advice of our doctor. After much protesting, they changed their policy. ES pharmacist reasoning "I used to work at a retail pharmacy where we let insulin sit out in the sun in the parking lot, and we never got any complaints about the insulin." Great, just great.
2. I have had insulin shipped warm to me several times. After protesting that I am not injecting my baby with warm insulin, the ES pharmacist said "Insulin is expensive and you're costing us a lot of money with these returns." I said my doctor was against it, and the conversation ended.
3. As of 1/1/2014 ES has eliminated over 75% of treatment options for diabetics - not cost more, eliminated. They have a regular appeals process, and then a special appeals process for the recent diabetic changes - which has not been communicated. Also I have been told appeals can last 2-4 weeks and the appeals have to be filed every 6 months, no matter the situation. I asked them what we were supposed to do on 1/1/2014 for medication for my son when there wasn't even an appeals process set up and they said "make sure you have enough medicine to get through an appeals process - when we finally tell you what it is." Distinct lack of understanding there.
4. My son has about 15 prescriptions filled at any given time, which always has errors on them when they are processed by ES. When I find an error, I have to call in and then it has to go through a several day process while they approve and fix the error. I asked them why they kept messing up his prescriptions. Answer: "Come on, your son does have a lot of prescriptions." ?!?
5. They are the insurance company AND the pharmacy, a huge conflict of interest. They say all the time "they are just managing my companies insurance benefit" and "they always follow doctor's orders" it is blatantly untrue. They ignore doctors' orders constantly (my son's covered insulin rejection) and make their own decisions (their elimination of diabetic treatment options, when my employer's insurance plan covers it) all the time.
6. Average call time is 20 minutes - most are 40 minutes. I have to call in at least 3 times a week, to fix errors, do appeals, find out status of items, clarify benefits, etc etc etc. I have a full time job and a toddler with diabetes, this is the last thing I need and my family suffers.
One time on the phone my husband asked the ES rep how they could do the things they do and they said "We cover 1 out of every 3 Americans. We can do what we want." Please dissuade your employer from ES, and don't give them more power to expand the monopoly and "do what they want".
There has been legislation and legal action in several states to address some of these issues, including respecting physicians' prescribing authority, aligning its interests with those of its clients, and the use of fair business practices including returns, shipping temperature sensitive medications, and developing a sound formulary.
http://www.express-scripts.com/sitemap/docs/AVC.pdf
http://www.thelundreport.org/resource/small_pharmacies_getting_squeeze_from_goliath_pbms
It doesn't have to be this way. Here's a much clearer formulary document.
I think it's worth telling people who can regulate, enforce regulation, and contract with (or not) pharmacy benefit managers at least what issues they should be looking into on our behalf.
That is great information, thank you. I see that legislation was from 2008, and wondering how much of that they are really doing given my personal experience.
I love that formulary document. I didn't find out for years that one of the supplies that we use was covered, and paid out of pocket for it the whole time. I get it for free now, but what else am I missing and entitled to under my plan?
To your last point, I will have to continue to find ways to affect change. My husband had already filled a formal complaint with the government on the approval of the Medco / ES merger which has made patient coverage worse instead of better as they claimed.
Hi Jack's Mom,
God bless you for what you go through with a baby with diabetes! I was wondering if you looked into reporting this situation to the Insurance Commissioner of your state. I don't know a whole lot about the process, but I had a friend do this as it related to her father's care, and it was taken care of in quick order.
Also, having had too many similar situations to even try and share, it seems to me, you are saving the pharmacy money and they are torturing you for it. Why don't you just have his MD write for the pens to avoid having to deal with the different prescriptions. It seems like this is added stress, increases the number of prescriptions, thus increasing the number of mistakes to be made....just use pens all the time.
Give that cutie a hug for me!
Thanks for your kind words Karen, that was really very sweet.
The Insurance Commissioner is a GREAT idea. We will definitely do that.
I like your idea, and have considered actually just ordering vials. My son is on a pump, so that's why we get the vials. They are a lot cheaper too - I can get six vials for $30 (6000 units) but the cartridges cost me over twice that for much less insulin (1500 units). It's just that when he is away from his parents - which happens a lot since we both work full time - and he needs an injection for any reason (high bg not coming down, pump failure, pump fell off, oh the tribulations of a toddler on a pump) we feel much more comfortable with people giving him an injection off his novo pen jr since his standard dose is a half unit. However, will think about this more. Thanks!
I will definitely give him that hug. He says hugs make him happy.
Is Jack on a glucose sensor too?
The cost is unfortunate, but you could get all cartridges and fill Jack's pump reservoir via the pen cartridges instead of the vials.
Also, are you using the 3/10 cc syringes which have the 1/2 unit dosage marking? Perhaps you can get the magnifier that works around the syringe and holds the vial....it may be easier for persons who are "guest" injectors....although I tend to agree about the pen being preferable.
I didn't know about the magnifier on the syringe! I totally need to get that. I am an older Mama and my eyes are starting to go south. Yes, we have the syringes with the half unit markings, but I've had someone confuse the half unit with the whole unit on the syringe which is the cause for my worries. That's a lot since it means double the insulin dose for my little one.
Here is a link to one brand: http://www.ambimedinc.com/section_products/insul-eze.html