Route 66 Motel

Due to the sensitive nature and HIPAA regulations, we have been instructed not to continue this dialogue based on the medications involved I would like to add that FlexScripts has documented processes in place over the last years Because we are not a fully insured insurance company, if a member cannot obtain their prescription, FlexScripts does not make any additional money FlexScripts provides self-funded administration of the employer plan This means that at any time, the employer could give us a call and recommend coverage for any member’s medication This has not occurredThank you for reaching out to us directly [redacted] | Senior Pharmacy Consultant / Director of Business Development

The medication in question was reviewed by FlexScripts Administrators based on our standard policy and procedure. It was not approved for payment coverage as the prescriber was requesting a non-FDA (Food and Drug Administration) dose per day. Confirmation of this non-FDA approved dosage
was also done in conjunction with the pharmaceutical manufacturer of the medication. FlexScripts is simply the processor for this employer group and does not make any additional revenue by deciding to cover or not cover medications (that is what Insurance companies do). Our clinical team offers recommendations on whether the employer group should allow coverage based upon FDA guidelines. At no time did FlexScripts or *** *** act outside of guidelines set forth by the FDA. Please let me know if you have any additional questions.Thanks,*** *** | Senior Pharmacy Consultant / Director of Business Development***

The
medication in question was reviewed by FlexScripts Administrators based on our standard policy and procedure. It was not approved for payment coverage as the prescriber was requesting a non-FDA (Food and Drug Administration) dose per day. Confirmation of this non-FDA approved dosage was also done in conjunction with the pharmaceutical manufacturer of the medication. FlexScripts is simply the processor for this employer group and does not make any additional revenue by deciding to cover or not cover medications (that is what Insurance companies do). Our clinical team offers recommendations on whether the employer group should allow coverage based upon FDA guidelines. At no time did FlexScripts or *** *** act outside of guidelines set forth by the FDA.
Please let me know if you have any additional questionsThanks,
*** *** | Senior Pharmacy Consultant / Director of Business Development
***

Due to the sensitive nature and HIPAA regulations, we have been instructed not to continue this dialogue based on the medications involved.  I would like to add that FlexScripts has documented processes in place over the last 10 years.  Because we are not a fully insured insurance company, if a member cannot obtain their prescription, FlexScripts does not make any additional money.  FlexScripts provides self-funded administration of the employer plan.  This means that at any time, the employer could give us a call and recommend coverage for any member’s medication.  This has not occurred.Thank you for reaching out to us directly.[redacted] | Senior Pharmacy Consultant / Director of Business Development

The company's response did not address my specific complaints, plus it included inaccurate and outright falsehoods regarding my medication regimen.
First, they stated they were only going by FDA guidelines regarding the dosing of the medication. The FDA does not provide any specific limitations on this medication; in fact, my Doctor had the drug manufacturer who made the medication fax information to the above company regarding dosing guidelines.
Also, they initially advised me they were denying the medication because it was prescribed twice daily. Flexscripts stated it was only approved for once daily administration. However, when my Doctor adjusted the prescription to reflect only once daily dosing, Flexscripts continues to deny coverage for the medication. I made several phone calls to Flexscripts, but was only advised my information had been "passed to higher ups," and refused to provide any further explanation.
Regarding the original prescription (for twice daily dosing), both my insurance company before Flexscripts and my current health insurance plan (I canceled the above plan and signed up with a different company) have covered the twice daily dosing, as prescribed by my Doctor.
I remain frustrated because they were paid for a service, and I was lied to frequently (and my Doctor threatened) due to either simple ignorance or outright greed. As stated above, even after my physician adjusted the dose to what they recommended, they still denied coverage. At no time did they offer a different medication out of that class of medications (per regulations from the Affordable Care Act).
I only hope no other patient has to deal with the utter ignorance and incompetence this company displays.

The company's response did not address my specific complaints, plus it included inaccurate and outright falsehoods regarding my medication regimen.First, they stated they were only going by FDA guidelines regarding the dosing of the medication. The FDA does not provide any specific limitations on this medication; in fact, my Doctor had the drug manufacturer who made the medication fax information to the above company regarding dosing guidelines.Also, they initially advised me they were denying the medication because it was prescribed twice daily. Flexscripts stated it was only approved for once daily administration. However, when my Doctor adjusted the prescription to reflect only once daily dosing, Flexscripts continues to deny coverage for the medication. I made several phone calls to Flexscripts, but was only advised my information had been "passed to higher ups," and refused to provide any further explanation.Regarding the original prescription (for twice daily dosing), both my insurance company before Flexscripts and my current health insurance plan (I canceled the above plan and signed up with a different company) have covered the twice daily dosing, as prescribed by my Doctor. I remain frustrated because they were paid for a service, and I was lied to frequently (and my Doctor threatened) due to either simple ignorance or outright greed. As stated above, even after my physician adjusted the dose to what they recommended, they still denied coverage. At no time did they offer a different medication out of that class of medications (per regulations from the Affordable Care Act).I only hope no other patient has to deal with the utter ignorance and incompetence this company displays.

Due to the sensitive nature and HIPAA regulations, we have been instructed not to continue this dialogue based on the medications involved.  I would like to add that FlexScripts has documented processes in place over the last 10 years.  Because we are not a fully insured insurance company, if a member cannot obtain their prescription, FlexScripts does not make any additional money.  FlexScripts provides self-funded administration of the employer plan.  This means that at any time, the employer could give us a call and recommend coverage for any member’s medication.  This has not occurred.
Thank you for reaching out to us directly.
[redacted] | Senior Pharmacy Consultant / Director of Business Development