Pharmacy benefits issue

Heeeey,

My issue is mostly resolved now but I am not sure if there’s any other complaints that should be made to other people for this situation.

I’ve been in a medication for the last 9 months or so, and getting it covered has not been a problem except for the last few months.

The last few refills have been a struggle to get covered. I first check with the pharmacy about why it wasn’t going through my insurance and they said the claims were denied and to call the insurance.

I did this and they first blamed the pharmacy but ultimately after a couple of calls they fixed the problem and told it was because they use a 3rd party cost savings software that checks the GoodRx price for the drug and then if the consumer cost is cheaper through GoodRx it denies the claim, since the customer would be better off with the GoodRx price.

Except with my drug it didn’t work and the GoodRx price was not cheaper—but it denied my valid claims anyway. They just had to disable the software for it to go through.

This first time they fixed pretty quickly, but last month it happened again and was not such a quick fix. I had to call multiple times and was told no one could help me even though they could tell it was the same problem. The delays ultimately led me to running out of my medication and experiencing withdrawals for a couple of days.

After it is finally resolved (I had to get my employers HR involved), the insurance tells me the same issue caused the problem and they’ve supposedly fixed it permanently but will not put that in writing for me. They also tell me that any of the prior reps on the many phone calls I made before running out of meds could have fixed it as well—they just didn’t know how or something I guess—she couldn’t explain that part.

My HR people apologized and told me they’d look into it, but the reasons the insurance gave to me and the reasons they gave to the HR people were completely different. I tried to point that out but they did not seem interested in that part.

My fear is that this software may error out on lots of meds and folks just don’t notice bc the price difference isn’t significant enough to make them question it. It clearly wasn’t fixed the first time or even the second (only for me individually). It just seems like a shady way of not paying valid claims.

It is resolved on my end so idk if I should let it go or report it higher up somehow? To who? we’re self insured so my employer already knows. I don’t know if there even is anywhere higher 🤷🏼‍♂️

TLDR: my pharmacy benefits manager uses software to automatically deny valid claims causing customers to potentially overpay. Now that it’s resolved should I just let it go or keep fighting?