• Report: #501997

Complaint Review: MEDCO - Medco Health Solutions

  • Submitted: Wed, September 30, 2009
  • Updated: Sat, June 19, 2010

  • Reported By: hturn — USA
MEDCO - Medco Health Solutions
po box 6052 parsippany, New Jersey United States of America

MEDCO - Medco Health Solutions will not reimburse prescription cost. Can someone help with this mystery? parsippany, New Jersey

*UPDATE EX-employee responds: This may help

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I am a lady that is living with cancer. After I was diagnosed andreached the point when I could no longer work my former employer filed incorrect termination dates with COBRA which led to a 5 month battle to get that problem corrected. During this 5 months I had no prescription coverage. All medication cost was paid out of pocket. When my insurance problem was straightened out I had to pay the monthly premium cost (6 months X monthly premium). I was told to submit receipts and pharmacy printouts to MEDCO for reimbursement. This is what happened and I promise it will show you how much these companies fight there customers.

With insurance you pay 1 copay for a monthly supply. It is normally a round figure like $ 10. With no insurance I had to buy 3 to 5 pills at a time. The cost is very high. Here is how they calculated there responsibility. This is an actual example.

I paid $38.59 for 3 pills (the copay for 30 pills is $40)

MEDCO replied saying the approved amount for this claim is $29.02. Copay amount is $29.02. Total payable by MEDCO is $ 0.00.

It goes on page after page. 95% of the specific claims have the approved amount as equal to copay amount. Leaving MEDCO owing nothing. Copay amounts are on a sliding scale. And this is the truth - the copay amount for 5 pills is more than the copay for 30, if you pay $50 dollars out of pocket or $ 5 the copay amount adjust magically to MEDCO 's approved amount, in the rare case that they agree to pay on a claim then the amount they say a drug should cost is applied and not what a national chain like CVS would charge!

Out of $2000 of prescription cost MEDCO with their in house formula agreed to pay (drumroll)

ONLY  (2000 X 0.07) of the cost, thats right %7. Has anyone else experienced this type of problem? Has legal action ever taken place for this?

 


This report was posted on Ripoff Report on 09/30/2009 06:25 AM and is a permanent record located here: http://www.ripoffreport.com/r/MEDCO-Medco-Health-Solutions/parsippany-New-Jersey-07054-7052/MEDCO-Medco-Health-Solutions-will-not-reimburse-prescription-cost-Can-someone-help-with-501997. The posting time indicated is Arizona local time. Arizona does not observe daylight savings so the post time may be Mountain or Pacific depending on the time of year.

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Updates & Rebuttals

#1 UPDATE EX-employee responds

This may help

AUTHOR: Joy - (U.S.A.)

I used to work for Medco, and that is an EXTREMELY common practice.  Here is the how and why.. Let's say you are getting drug X from CVS.  If you walk in and say you are paying cash, unlike Doctors offices who offer cash discounts, pharmacies see dollar signs.  Because as a cash patient, you don't have the legal and volume backing insurance companies do.  So, as a cash patient, Drug X through CVS is now $15 per pill (all dramatizations for clarification purposes.) However, if you show them your Medco card, CVS lowers the price to $7 a pill for Medco. ok, in theory, that sounds about right. Bulk buyers get discounts, but here's where is screws you.  There is a U&C price (usual and customary) and that price is about $11 per pill for this drug.  And of course CVS wants to make a profit on it, so the raise the cost to $15 per pill.  Now, your insurance was unavailable to you for 5 months, so you paid the $15 per pill.. But Medco will refuse to pay over the $11 per pill, because that is above and beyond the U&C charge.  That would be bad enough on it's own, to lose $4 per pill, but it gets even worse. 
Co-payments are not calculated on a per month basis, but a PER DISPENSING basis. So, you said your copay was $40 per dispensing, whether you got 5 pills or 30 (which is common practice.  It's called Flat-rate co-pays.  And it can benefit you, if your insurance is working well, and you are buying large amounts of expensive meds.) There is also another practice called percentage co-pays.  That is where you pay a certain % of the total cost of the medication.  If you were paying $40 per fill, you have flat rate.  Well, since you were buying your pills 3-5 at a time, they are considering that as each $40 dispensing.  Which means, each time you filled a few pills they "assume" you would have paid the $40 each time.. and since each total was actually $29, they consider that less than the $40 co-pay, so there for you "saved" $11 per dispensing.  They don't take into account, conveniently, that you would have only filled it once the whole month, with the total amount of pills, had you had the insurance active. 
Here is what you need to do if you want to receive some sort of resolution.  Since I do not have access to your BCBS info, you will have to call Medco again.  Tell them you need to speak to an RTL (resolution team lead) without exceptions, that you will only work with them.  They have to transfer you at that point.  Then explain the situation to them, and give them a chance to resolve the issue.  If they say they cannot or will not, then ask for the ERISA appeals process information.  At this point, you are essentially beginning legal action against them, at no cost to you.  Further more, a nice letter, with signature confirmation to David Snow, the CEO, in New Jersey, also does wonder's for getting what you want taken care of.  Good Luck!  And I hope you have a speedy recovery!
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