A Tricky Way in Which Your Coverage for Essential Medications May be Denied

We all know that the American healthcare system is a complex one with a lot of bureaucracy. One such complexity involves how prescription medications are handled. Pharmacy Benefit Managers (PBMs) process prescriptions for insurance companies and corporations, using their size to negotiate low prices with drug makers and pharmacies. Essentially, they act as the “middlemen” between the payer and everyone else in the healthcare system.

Recently, a PBM named Express Scripts, adopted a policy to block coverage of approximately 1,000 ingredients used in compounding; they made this decision for no other reason than to cut their expenses. They actually went to the extreme of denying coverage to thousands of patients; this is against federal rules that govern the handling of health plan claims. The law requires that the claims handler disclose the specific reasons for a claim decision, including specific reference to the health plan provision(s) upon which a “not covered” claim is allegedly based. The law was structured this way to help patients determine whether denials can be properly challenged. However, Express Scripts is covering up its financially-motivated decision by issuing intentionally deceptive and misleading letters to patients, informing them there has been an unspecified change in the compound medications. Letters to patient have further suggested that there are safety concerns over compound medications.

Imagine suddenly being denied coverage for an essential medication that you take! Compounded medications are a vital part of natural health. They include such critical products as thyroid medication and estriol, the bioidentical form of estrogen.

Three compounding companies (Annie’s Apothecary, Cypress Compounding Pharmacy, and Wiley’s Pharmacy and Compounding Services, Inc.) are suing Express Scripts for its unlawful decision to drop coverage of ingredients used by compounding companies.

Action Alert! If you have not done so already, please add to the pressure on Express Scripts and other PBMs by reminding them they have no authority to countermand a doctor’s healthcare directive with their own assessment of what is “medically necessary.” Show them how important compounding is to families like yours. As important as the lawsuit is, consumer pressure is also needed. Send your message today! Simply visit the Alliance for Natural Health’s website and fill out this form with a letter already formatted.