6 comments

I'm yet another CalPERS member with this problem.I've had an Anthem PPO plan for over ten years, and I've been taking medications requiring prior authorizations the entire time.

In the past ten years, not a single one of my PAs has been denied...until now. Sure, Medco and Caremark occasionally gave me problems ("lost" approvals, unnecessary extra requests, etc.); however these problems NEVER included denials. Since January 1st, several of my co-workers have reported long delays with their PA approvals. Well, it's amazing how quickly they respond when they decide to deny it!

I've requested two PAs in the past two weeks, and both denials were received within 48 hours of the request. Now my only option is to spend almost half of my paycheck on a one-month supply (because if I don't I'll end up in the hospital). Oh, and as if that wasn't bad enough...Both times they denied me, I was notified by automated phone calls on weekend days (one Saturday, one Sunday) at 7AM on the dot. Thank you, OptumRX, for interrupting the only quiet time I have all week (and waking up everyone else in the house).

I ignored the 2nd 7AM call and turned off the ringer...at 10AM I checked the caller ID, and they'd literally been calling every fifteen minutes! Apparently messing with peoples' health just isn't enough fun for them.

If these issues aren't addressed soon, the state will have a helluva problem to deal with.Productivity will go down the toilet if half of the workforce can't get their meds.

Review about: Optumrx Customer Care.

Reason of review: Denial of coverage.

Monetary Loss: $900.

Preferred solution: Medication coverage.

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Anonymous
San Marcos, California, United States #1342070

Keep getting calls about my wife's meds from Optum Rx and they want her to speak "with a pharmacist".Get calls at least 1x per week.

The "pharmacist" says his name is Sam but refuses to tell her from what state he is calling from or what his pharmacist registration number is---according to Optum Rx Law, he does not have to....! A physician treats and prescribes therapy regimens, not a "pharmacist" albeit they are authorized under CA SB 493 (1/1/2014) IF they work in concert with the treating physician----which is not the case as the treating physician has not entered into an agreement with Optum Rx "pharmacists" to co-treat. Told them to stop calling. CalPERS needs to look at this contract and get it fixed.

Co-pays go up arbitrarily and they don't or won't justify their reasoning.

Open enrollment is just down the road----notice the TV advertisements for Optum & United Healthcare----their parent organization?

Anonymous
#1317574

My concerns with the telephone call is that it tells you to call this number and then the woman reads the number so fast that you can only get about three of the numbers.It certainly isn't a user friendly response.

There is a concern with logging in and the delays with password recognition.Cumberson.

Anonymous
#1317541

I have been a calpers member for 31 years.Never had a problem until Optumrx.

Obviously Optum RX was unprepared for a transition to such a large account, Obviously untrained staff, but biggest problem is glitzes to computer system. Despite it being almost May they (both Optum and CalPers) have been unable to provide online access for me which is almost like having no access to prescription care.

Baed on my experience this contract with Optum Rx by Calpers was based on something other than service or expense.The board needs to review this contract.

Anonymous
#1302460

I'm a patient who happens to be a doctor with some sense of how to navigate a pharm management system.OptumRx is the flagship of obstructionist policies and procedures that drive doctors into early retirement.

Floored that they denied a medication I've been taking for 33 years, it has taken 3 days with hours of calling in finding out why it was denied, and then determine the next hoop to jump through in yet obtaining their authorization to get this medicine. I ran out weeks ago and should have refilled in January. It is now March. This is inexcusable.

Deliberate indifference by way of policy does not mitigate exposure risk, in obviating liability. Talk to the 9th Circuit if you think it does.

My neurologist, whose practice is not devoted solely to my care, also has a life and other patients to see. Her contact will be the FIFTH contact required of this burdensome system to get a medicine I have never been without or denied in that entire past 33....

THIRTY THREE years.

Hiding behind a formulary "just changed" last year, and straight out of an accounting firm instead of contemporary medical research, they request peer reviewed literature be submitted for as helpful following the first denial for for authorization. Apparently doctors are required to abandon patients so they can hop on down to the library and get journal articles for the high school graduate who will then review it to determine authorization. NOTHING against high school graduates....nothing...

just be clear they are asking doctors for peer articles (etc) that will be reviewed by a high school graduate in determining whether or not they will authorize the doctor's prescription. Apparently THIRTY THREE years of several doctors judgment and prescribing the same medicine titrated over time is meaningless, against a journal article. Evidence based you say? There is no research study on a patient taking this medicine for 33 years.

AND it was normed on children between the ages of 6-9 (roughly), in the original FDA patent.

Once you submit journal articles reflecting adult dosage, you will get a second denial by a different person without the credentials to review it.

CALPers... you are paying for a 2 review process absent anyone credentialed to review it a second time.

So basically you are paying for someone to say no twice...absent the credentials to review it even once....

We are now at the appeal process. So a neurologist has interrupted the care of other patients for what will be a 5th time, done a book report, faxed info in 3 times, and this 5th time will have a quote "peer review" discussion, in obtaining authorization for a medication that has NEVER been interrupted in 33 years, and I am now almost without. And, the absence of which is now precipitating blood sugar regulation problems secondary to disrupted circadian rhythms caused by an absence of medication.

It it reprehensible that this process is so obstructionistic that it puts one at the threshold of diabetes, absent any accountability other than a formulary they just changed last year (upon being awarded the contract). Deliberate indifference by way of policy does not negate liability. It seems the people with CalPers need to find a voice that will be heard constructively in voicing these concerns to the CalPers Board such that corrective action can be evaluated and taken. Going straight to Class Action litigation, doesn't give them the chance to evaluate and respond.

If anyone has any good ideas for forwarding these concerns to the CalPers Board, it would be really helpful to pass that along so we can all contact them with feedback.My sense is, this isn't going well, and the more they hear, the greater the likelihood they can take corrective measures in protecting their CalPers people.

Anonymous
Walnut Creek, California, United States #1283993

Same problems here, 7am denials for medications and poor customer service. Guess we are going to need lawyers to get medicine.

Anonymous
to Rodney #1302461

Yup. Class Action. I give it till June at the longest.

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