InsuranceFilter: What exactly makes a medication fall into the maintenance medication category in the eyes of insurance companies?

October 3, 2008 9:17 AM

InsuranceFilter: What exactly makes a medication fall into the maintenance medication category in the eyes of insurance companies? Is it the fact that the doctor writes the prescription and allows for refills? Would getting a new prescription with no refills every month circumvent the whole maintenance medication designation?

My husband and I have medical insurance and prescription insurance through his employer. For the past 6 years, the companies have been easy to deal with and we've always had great coverage with lots of options. Just recently (within the past 2 months) the prescription insurance - Express Scripts - struck some kind of deal with my husbands employer and now they are making it mandatory that we use their mail-order pharmacy for any medication that they consider to be routine/maintenance medication. I have no desire to use any mail-order service for my medications and I am resentful of the fact that this is being forced down my throat. I feel that there is something fishy about the fact that they are not even allowing a choice of mail-order pharmacies, but instead are mandating that we use theirs OR pay 100% out of pocket for our medications... Also then we face the possibility that the company will sell detailed claims data on prescribing and dispensing history which drug companies often use to target sales efforts. I don't want someone selling my medical information!!! They infer that fact themselves on their own website:

"Business Associates: We arrange to provide some services through contracts with business associates. On occasion, we may disclose your medical information to business associates acting on our behalf. If any medical information is disclosed, we will protect your information from further use and disclosure using confidentiality agreements."

So I guess my question comes down to this - what exactly makes a medication fall into the maintenance medication category? Is it the fact that the doctor writes the prescription and allows for refills? Would getting a new prescription with no refills every month circumvent the whole maintenance medication designation?

I really want to find a way to beat them at their own rules and would appreciate all insight, suggestions or guidance that any of you may have to offer!

posted by lrkuperman to health (7 comments total)

Good luck, but I have doubts about you being able to "beat the insurance companies." IANAP (pharmacist) but I would not think that getting the "no refills" option would circumvent the whole situation. Or if on the off chance that it did, I can only imagine that you or your doctor would tire of writing or attempting to receive prescriptions on a regular basis, thus in fact making it a maintenance medication, annoying your doctor and be honest, yourself.

Having had to use mail order medication maintenance in the past, i found it initially obnoxious to deal with but eventually found my way through the fog and it then became easy and not much trouble.

I hope someone else's comment will be of better help.
posted by wocka wocka wocka at 9:33 AM on October 3

A maintenance medication is any drug taken regularly for a continuing condition, including high blood pressure pills, diabetes meds, anti-inflammatories for arthritis, cholesterol pills, etc. An antibiotic for a sudden infection is an example of something they'd allow you to purchase at your local pharmacy with only your co-pay. But even if you convince your doctor write you monthly scripts with no refills, the insurance company will catch up with you eventually and determine it to be a maintenance med.

I once worked for a company whose Blue Cross plan suddenly switched to the mail-order prescription scheme; I was very upset at first, but I eventually found that it had its pros and cons. One pro was they had raised our co-pay from $5 to $15 some time prior to the mail-order option, and now that we could order a three-month supply at a time, it put us back to the $5 co-pay level. It also meant not having to stop at the drugstore to pick up pills. On the other hand, our mail-order company (Merck) screwed up orders far more times than Walgreen's ever did; we'd place our refill orders, they'd get lost in their "system" or duplicated, yada yada. (One other plus of their ineptitude is that they kept sending me bottles of the pain-killer Ultram, even after my prescribed number of refills had expired. And when I called to say cease and desist, they never charged me for all those extra pills.) I never read the fine print on our contract, so I don't know whether or not Merck sold any of our medical info.
posted by Oriole Adams at 9:54 AM on October 3

Well, if you get the prescription filled at a local pharmacy, and your insurance pays for it, your insurance company is still getting the data on your prescribing and dispensing history.
posted by dcjd at 9:56 AM on October 3

I believe HIPPA protects your medical information. However, if the insurance company is outsourcing mail order prescriptions to a third party, they sort of have to provide that third party with your name, id number, dependents, conditions etc etc otherwise how exactly is the third party company going to do their job? The insurance company and the mail order pharmacy are almost certainly electronically linked, and if you follow the ownership trail, it's quite possible that they are both at least partially owned by the same parent company.

If you want the benefits of insurance you have to play by the insurance companies rules. It's not being forced down your throat. You are free to discontinue your insurance and pay out of pocket for your health care at any time, or at least an annual renewal time.
posted by COD at 10:17 AM on October 3

Getting a new script every month will not work -- prescription insurance billing systems only care about when you get drug X filled, not how many refills are on the prescription.

HIPAA places pretty strict limits on what companies can do with your health information (to the extent that some kinds of medical research have become more difficult since it was enacted, due to privacy limitations). If they do share information, it will be in aggregate form only without any identifying information. I'm pretty sure they're also strictly forbidden from using your medical data for any commercial or advertising purposes.
posted by neckro23 at 11:20 AM on October 3

I am also fairly certain that Express Scripts is forbidden from sharing your personally identifiable medical data due to HIPAA. Why would they risk lawsuits?

I'd used Express Scripts for years at my old company and on my old insurance. There was nothing fishy about it, I never once had a screw up with my medication, it saved me money on copays, and it really wound up making my life a LOT easier to not have to stop at the pharmacy every month. It just doesn't seem like it's worth it to bother with trying to get around the system, since it probably won't work anyway.
posted by tastybrains at 1:49 PM on October 3

Express Scripts gets generally good reviews (e.g. 82 points for customer satisfaction in a Consumer Reports survey, top score was 84).

I believe the wording that concerns you refers to "business associates" such as UPS or FedEx -- who need to know your information to deliver your drugs. It isn't the type of language you see in terms of giving your information to people who want to send you ads or credit offers.

My mother has recently been forced to switch to Express Scripts even though they live two blocks from a Walgreen's. The initial set-up for each drug is a hassle, especially if there are limited refills, but after that it probably gets easier.
posted by dhartung at 2:15 PM on October 3