Question about sponsor
I have a prescription I cannot get filled. I have only been with my employer a year and a half and have already had three PAs on this prescription. My doctor has tried every possible way to get 60 pills for 30 days-2/ day. Or at least 1/day.
Initially, I was told that the prescription couldn’t be filled because it would have violated the 90/75rule. I pointed out that at no point in time has the pharmacy filled my prescription as written. I was only receiving 30 pills a month- 15 day supply- and stretching it to a month. The last prescription I filled was August 4th. I stretched it to September 4th thinking I would be able to get another 15 day supply. My six month prescription had run out at this point, even though there were more refills left. A new prescription was submitted. I thought I could fill the script. Pharmacy won’t fill it. Even though I have three PAs and was told they would be valid for a year, they said they won’t fill until October 18th.
My insurance has submitted an overdrive and I should be able to fill 15 days again tomorrow, but not the full script. When I asked why this has continued to happen, I was told it was the sponsor. I clarified that by sponsor they meant my employer. They confirmed that my employer is the one rejecting the prescription. How? I understand they have plans to choose from, but with the PAs that are seemingly approved, how can my employer go back and determine it doesn’t align with the agreement they have with the insurance company. Why would my insurance authorize something without checking if it aligns with the agreement? Why is my employer able to dictate something so specific?
I don’t know if it is my insurance or my employer now, but “they” have tried several other tactics to switch my medication. Once they told me that the only authorized medication was the formulary, but since generic was available, they had to fill the generic, but the generic wasn’t covered. Then they told me that the condition I have , which is idiopathic was not covered because the cause had not been determined, however the same condition that is not idiopathic is covered by this medication. The only reason it is idiopathic is because they won’t pay for the testing to find out the cause of the condition. I feel like I’m going crazy.
How do you navigate this? I don’t even think I can report them for anything because while I would think that ignoring the prescription would be reason to report them to someone, but they are so open about the fact, I don’t think it matters. What do I do?
