HMO railroading to use ONLY their Pharmacy Benefit Manager

[drpauljordan]

What is the name of your state?NY
I signed a new Enrollment Agreement effective 01Feb2006 as I have done for the past 15 years. The HMO has had 'Medco Health Solutions' as a "phamacy benefit manager." No sooner had the ink dried where both the HMO and I agreed to quite specific terms regarding 'what is' and 'what is not covered.' Within 2 weeks after the new agreement became effective, Medco (the HMO's benefit manager) sent notice to me on Medco letterhead, that they will be the ONLY source [by Mail to Ohio] to fill my prescriptions and will pay their price along with my copay to the HMO. The medications, at a local participating pharmacy, are less expensive that Medco's demands. The HMO feels that they have an agreement with Medco as "phamacy benefits manager" and is fine with the HMO that regardless of the quite specific contract just signed with the HMO, Medco can make this demand.
This is not what I agreed to, in writing or orally. I pay my premiums to the HMO, not Medco.

Is this railroading legal? The benefits manager demanding that I purchase prescribed meds from their company only? Seems a bit self-serving and somewhat convenient for Medco yet costs me more, in addition to the increased premiums. [url]http://forum.freeadvice.com/images/smilies/confused.gif[/url]


Any suggestions / assist or guide would be much appreciated.
My next step(s)? Contact the State Attny General and NYS Insurance Commiss?

[ecmst12]

I'm a little confused about what you got in the mail, but if your prescription plan works like most others you can take your card into any participating pharmacy and pay your copay and get your meds there. If you want to get your meds by MAIL ORDER, you have to go through Medco's service.

[drpauljordan]

Contract with HMO states: 1. go to participating pharmacy (this I have done for 15 years) 2. Option_use Medco for 'mail order" for meds to be sent. That was the recent contract with HMO.
Letter from Medco: "You can go to pharmacy for initial Rx." However, the next refill MUST be through Medco or I am responsible for all payment to local pharmacy. NO CHOICE was provided by Medco, either I use their Mail Order Services or pay full amount if I 'chose' to fill 2nd Rx locally since they will not pay pharmacist as in the past.
Clearly, they (Medco) have only ONE option: use their Mail Order! or total responsibility is mine.

[ecmst12]

That's kind of strange...of course you will save money by filling through mail order for maintenence meds, but I haven't seen where they FORCED you to use it. Did you call customer service to make sure you're interpreting this correctly?

[averad]

It is strange quite strange but you are on a HMO and your not free to just go to any doctor. call CS and verfy and if you have to use Medco your just going to save time and trips to the pharmacy.

[drpauljordan]

Thanks for the input. I spent over an hour with CS and CS Supervisor asking for an explanation. Supervisor stated that when I did my annual renewal that I signed up for their "SuperSaver" pharmacy program. First time I've ever heard of such a program so I asked where in my new 'benefit package' or better yet, in my contract where it clearly states that I have a deductible and copay as long as I use any one of the listed or network pharmacies. Same wording as the last 10 years. I asked CS supervisor where I could find the 'supersaver' information or could he send it to me? The statement was "it is an electronic document." I then explained that I would be pleased to receive any electronic document by encrypted e-mail, regular email, or by any method, including having the HMO print it and mail it. After 5 minutes on-hold, I was told that "no one could locate the electronic document now" and that "it was made available to insurance reps with the 'supersaver name' for marketing." Folks, I couldn't make this story up even if I attempted to write fiction! The CS Supervisor's last suggestion was that he 'could change my phamaceutal package now if I did not want to keep the SuperSaver (which seems not to exist anywhere).' However, there would be an additional 12% added to my yearly premium and the deductible would go from $100 to $250.
I am sitting here quite dumbfounded after this phone call. What next? Is my orignially signed Feb 1, 2006 contact (signed by myself and the HMO) a legal contract or not? It is quite specific in what it does and more importantly, does not cover. Meanwhile, the pharmacist says that his computer tells him he will not be paid by the Prescription Benefits people at Medco if he refills any Rx for myself or family.

[averad]

Ask for a copy of the document you signed agreeing to this new benifit. They are legally required to maintain enrollment applications for (dont quote me) 4+ years. If they cannot provide documentation showing you applied for this new benifit request that you are placed under the benifits you signed up for. If they still refuse you need to get representation as you will be dealing with the Insurance Board.