Express Scripts: Tips and Tricks?

[Princesca]

Another year, another year of getting everything denied by Express Scripts. Seriously the WORST health insurance experience I have ever had. My wife has an ear infection and they even rejected her for Prednisone today, which the doctor had prescribed. It was $5 with a coupon, so this is not a controversial or expensive medicine. I'm so tired of it.

Does anyone have any tips/tricks for getting prescriptions approved/filled via Express Scripts? I'm near to wanting to look for another job just so I don't have to deal with them anymore.

 

[DLgal]

Express Scripts is just a pharmacy contractor
like CVS or Walgreens. Approval is dependent upon your insurance company. We have never had an issue with Express Scripts. If you are having issues with your Rx, contact your health insurance company.

 

[Princesca]

Express Scripts is just a pharmacy contractor
like CVS or Walgreens. Approval is dependent upon your insurance company. We have never had an issue with Express Scripts. If you are having issues with your Rx, contact your health insurance company.

That's really weird because when I contact my health insurance, they say I have to talk to ES. :/

 

[DLgal]

That's really weird because when I contact my health insurance, they say I have to talk to ES. :/

Approval issues are at the insurer level. If Express Scripts is having something like a supply/inventory issue, sure, talk to them. Did you call them and ask what the problem is?

 

[Princesca]

Approval issues are at the insurer level. If Express Scripts is having something like a supply/inventory issue, sure, talk to them. Did you call them and ask what the problem is?

The last time I called, the issue was with a prior authorization. I asked my insurer and they said that ES handles all those.

 

[DLgal]

Which company is your health insurance through?

Express Scripts is primarily for maintenance medicines via home delivery. If you have a short term Rx for an acute issue, you would fill that at a retail pharmacy like Walgreens or CVS.

 

[DLgal]

The last time I called, the issue was with a prior authorization. I asked my insurer and they said that ES handles all those.

Prior authorization needs to come from your doctor. It basically is a form the doctor has to fill out saying the medication is necessary and that other (cheaper) options have been tried without success. Again, the requirement of prior authorization is mandated by the insurer, not the pharmacy. Your insurer is giving you bad information. Talk to someone else.

 

[SLThomas318]

So Express Scripts is a pharmacy benefit manager AND a pharmacy. The contract they have with your company dictates what is covered or what needs prior authorization... they manage plans for tons of companies. When you fill something at your local pharmacy (i.e. CVS, Walgreens) they bill express scripts and whether or not the medication is covered is determined by the contract they have with your particular company. They can also provide your medication via their mail order pharmacy (again all determined by the contract with your company). You should have a member services number on your insurance card that you can call when you have issues and they will also be able to explain your coverage (at least they should, but call centers can be hit or miss with giving good information).

 

[lanejudy]

My Rx coverage is through Express Scripts, Express Scripts is the PBM as well as the mail-order pharmacy. Routine maintenance medications are filled through Express Scripts. Meds for acute issues are filled at the local pharmacy; if it turns into a longer-term need, it can only be filled locally 3 times and then must be switched to Express Scripts.

OP -- are you filling the prescription locally? While prednisone is not an expensive product, it's not usually the first-line treatment for an ear infection (usually basic antibiotics such as amoxicillin). If your wife has had a recurring issue with the ear infection or for some other reason needed a second-line product, the doctor should have been prepared to submit a prior-auth for prednisone.

 

[DLgal]

So Express Scripts is a pharmacy benefit manager AND a pharmacy. The contract they have with your company dictates what is covered or what needs prior authorization... they manage plans for tons of companies. When you fill something at your local pharmacy (i.e. CVS, Walgreens) they bill express scripts and whether or not the medication is covered is determined by the contract they have with your particular company. They can also provide your medication via their mail order pharmacy (again all determined by the contract with your company). You should have a member services number on your insurance card that you can call when you have issues and they will also be able to explain your coverage (at least they should, but call centers can be hit or miss with giving good information).

This, exactly.

OP, every insurance company has a formulary for what they cover when it comes to prescription medications. You should have access to that formulary online via your insurance company (not express scripts). Just google (your health insurance plan name + pharmacy formulary). The formulary tells you whether a drug is covered, whether it needs prior authorization, etc. These decisions are not made by Express Scripts, but by the health insurance company.

We have had issues at CVS (our Rx plan is managed by Express Scripts) where we are told "insurance won't cover this Rx" and we look up the formulary for our health insurance plan and it's a matter of quantity sometimes. Like, certain medications they will only cover X number of pills per 30 days and the doctor wrote a larger quantity on the Rx, so its a matter of changing the quantity and resubmitting. This just happened recently with some migraine meds for my husband. Doctor wrote quantity "30" but insurance would only cover 9 at a time. The CVS employee couldn't see that as the reason for the denial, it just shows "not covered as submitted" and it's up to the patient to figure out why and fix it. I could have called the ES customer service and spent who knows how long on the phone, or I could just quickly look it up in the formulary to figure out the issue, which is what I did (and which took all of one minute).

The other time we had an issue was when attempting to fill a 90 day supply of a maintenance medication at Walgreens when Express Scrips was pushing for those to be filled via mail order pharmacy. They gave up on mandating that, but we got caught up in the couple months where they were denying these at retail pharmacies and ended up paying out of pocket at the time and submitting claims for reimbursement later.

So yes, sometimes you will run into roadblocks with Rx, but this happens to EVERYONE from time to time, regardless of who their pharmacy benefit manager is.

 

[tvguy]

Express Scripts is just a pharmacy contractor
like CVS or Walgreens. Approval is dependent upon your insurance company. We have never had an issue with Express Scripts. If you are having issues with your Rx, contact your health insurance company.

And if you are getting this coverage through an employer, and something is not covered, take it up with your HR department so they know that medicines that their employees need so when they consider what prescription coverage to offer the next year.

 

[barkley]

OP, every insurance company has a formulary for what they cover when it comes to prescription medications. You should have access to that formulary online via your insurance company (not express scripts). Just google (your health insurance plan name + pharmacy formulary). The formulary tells you whether a drug is covered, whether it needs prior authorization, etc. These decisions are not made by Express Scripts, but by the health insurance company.

it can be helpful to set up a link to the formulary on your cell phone so that when you are at your doctor's you can instantly look up what med is being considered so if there's an issue with it being covered it can be immediately addressed. my son has had a couple of meds that our insurance wouldn't cover so i checked around to see what my least expensive option was, it ended up being costco so although we don't use them for our insurance covered meds we do on occasion for uncovered ones (and they accept the goodrx which can provide additional discounts).

 

[notatallmagic]

Not a fan of Express Scripts. Still waiting on an "emergency" shipment of insulin to replace the shipment that I'd tried to cancel multiple times (it arrived while I was in Florida) that was frozen to my porch after sitting for five days in sub zero windchills. It's been over a week, again, this is an "emergency replacement" shipment for a condition where you die without the medication. I've spent at least 10 hours on the phone with them. You couldn't have worse service if you tried. Awesome.

 

[tvguy]

it can be helpful to set up a link to the formulary on your cell phone so that when you are at your doctor's you can instantly look up what med is being considered so if there's an issue with it being covered it can be immediately addressed. my son has had a couple of meds that our insurance wouldn't cover so i checked around to see what my least expensive option was, it ended up being costco so although we don't use them for our insurance covered meds we do on occasion for uncovered ones (and they accept the goodrx which can provide additional discounts).

My issue has been with Tiers. My Doctor put me on two HEAVILY advertised medicines and it comes up as covered, and it was. But after he prescribed them, CVS Mail order called to warn me my out of pocket for a 90 day supply for one would be $450, and $200 for the other. I got my EOB statement and my Prescription insurance had paid $1,600 for one, and $1,500 for the other. Yup, the discounted price for each drug was $2,000 for a 90 day supply. I know how they pay for all those TV ads.