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OptumRx is not real forthcoming with their process.After they deny the two pre-auths, you can immediately appeal and ask it be submitted for review.

CalPers members get two instead of one Pre-auth review. The CalPers Board thought it was protecting its members by asking for a review x2 to assist members in timely receipt of their medicine. OptumRx figured no one was going to actually vet their process, and either charged more or wrote razzle dazzle language giving the impression they actually had a viable process that helps the CalPers members get timely meds. It probably helped in the awarding of the contract In reality, the same office with the same (very nice) people review the doctors script submission both times its submitted.

The second time its submitted, its reviewed by a "specialist". Near as I could tell that does mean credentialed expertise (nurse, doctor, PA, NP ) but is a person who processes the claims specific to that genre of need. There is no one there with the credentials to review additional information to substantiate the medicine or the amount... So they will ask for it and you can submit it for the second review, and it will change nothing in the outcome.

So, if they said no the first time, they will say no the second time unless its a typo, or you prescribe consistent with their newly revised formulary which is 2nd world, financially driven absent contemporary medical research (at least in my specific case). After that second denial, you can initiate an appeal for review. That different office is likewise primarily staffed with really nice people who are not credentialed to make medical decisions. However it seems they have access to individuals who are.

By their newly revised definition of "peer", your doctor can talk to a pharmacist as a peer, in determining medication and dose suitability. Not sure yet how that plays out. If you are not satisfied with that decision, from the appeals review, you can contact the State of CA and file with them. I'll check back for your response and leave that info in here, if this is still a live thread or you still have concerns.

Also, it will really help when you get a denial to write to the address provided in that letter and clearly state the request for those research studies and/or information with citation (author, title etc, FDA # and info, and so on). upon which the formulary is based. Keep this documentation for any Class Action lawsuit emerging from this. Though hopefully CalPers is given the chance to make this right, and they deserve (imo) notice and opportunity to intervene.

Many companies are not used to California's demand for accountability and Agencies that support the demand for accountability. This company is based in Arkansas... Maybe its time we help them see what makes public servants in CA such great people..... the CalPers Board has a lot of variables to juggle in meeting the demands of taking care of its people.

I doubt any of this is okay with them. Somehow they have to get word this is going on, as by my account, its erupting all over the place, and it only getting worse. No Agency, Board or Director is going to support some company coming in and making huge profit off the health and well-being of its members as some kind of easy picking cash cow. We're the second largest behind US Gov something in the purchase of health care.

But those vendors have to earn our business and don't get to reap excessive profit because no one can figure out how to get their meds.Don't give up, don't give in, we're CalPers members and we need to look out for each other in taking care of each other so we continue to thrive.

Review about: Optumrx Prescription Refill.

Reason of review: Policy Based Denial of Medication.

Preferred solution: Hire credentialed people with authority to deliver services the unit presents as offering (and can't/doesn't). For starters..... 2) pre-auth and appeal process horribly vague and not well defined. CalPers members are sticklers for accountibility. .

I liked: Some staff in pa very helpful, Staff did what they could to help.

I didn't like: Changed formulary after 49 billion dollar contract awarded, Catchy slogans like evidence based hides profit from denials, Demands physician treat their paperwork and not patient.

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Anonymous
#1376065

OPTUMrx

What a joke.We have tried repeatedly to get meds that we have taken for years with no avail.

We are now paying over $400 a month to get the meds that had a low copay before. Now they won't cover any of what we take. WTF?

That's close to $5000 a year.OPTUMrx needs to go....NOW

janericci
to Kathryn Wing #1388903

Calpers members are worried about their money, but do not seem to care that the TAXPAYERS of California as pi$$ing away their tax dollars for an insolvent, unfunded liability.Since Calpers members are "sticklers" about everything, why not watch where your and how your $$ is being handled by the clowns in charge of Calpers?

Just another crooked employee group with the lunatics are running the asylum.By the way as a long time professional work comp litigator, you need to educate yourselves....the pros and cons of every letter of your contract with Optum, etc have been negotiated with the Calpers/mob bosses, so please gaze more deeply into your collective navels and ask yourselves how you landed where you are right now with your medical insurance, work comp plans and PBM.

Anonymous
Sacramento, California, United States #1327067

I have had a cheap generic denied because it were not on the CalPers formulary.

I also get this message that it is not FDA approved.This particular med, a topical solution for Roscea, has been in use since at least the 1940s and is cheap.

I have been using it during the reign of CVS Caremark and Merck with no problem, it is just Optum RX that denies it.The med is a sulfacetamide cleanser.

Anonymous
San Carlos, California, United States #1303677

I have been paying $20 per month for one of my meds prior to Optumrx.When they became the pharmacy, the same med went up to $50.

When I called them to see why they are charging me more than the prior contracted pharmacy, they simply said that they changed the tier of my med to a more expensive tier (internal process).

Isn't there any watch dog authority?Why and how were they selected as our pharmacy?

janericci
to Anonymous #1388905

Your PBM (Optum) was selected by your Calpers mob bosses and yes the formulary was hammered out by these bosses...every last word was approved by them.Plus you must realize that in general your $50.00 per month more than likely doesn't come close to the true cost of your medications.

The plan, not unlike SSN counts on future and new members $$ to fund old/current members' drugs. In work comp I have seen people like yourself whining about $50.00 for a medication that costs $900.00 per month...who picks up the rest of the cost???

The other $uckers in your plan.The sense of entitlement in this country is awful...everyone cannot get everything they want for free....because the "rest of us" will run out of $$ supporting government unions.

Anonymous
Klamath Falls, Oregon, United States #1302902

CalPERS isn't getting what we are paying for. OptumRX say they never received faxed prescriptions -- twice, even though I've confirmed the fax number both with them and with my doctor.

OptumRX has yet to acknowledge or reply to the emails I've sent to their customer service asking questions about how to use their website - I don't see any way to order refills except to download, print, fill out and mail in a mail order form.

I've ended up having to have my doctor fax prescriptions to my local pharmacy instead, which is fine except I can only get 30 days prescription there and so end up paying more.

Anonymous
to Anonymous #1303273

I have to believe that CalPers Board did not intend for doctors to spend 15 minutes with the patient and (in my case) in excess of 3 hours combined doc, and nursing staff, to get approval of the medicine the doctor ordered....or delivered to the patient if approved.

Haven't yet found a website for direct feedback to CalPers, if I do I'll put in here for ya. You can always tweet #Calpers and let them know, which I hope you do. They won't know its broken if no one bothers to tell them.

You can also go to CalPers Twitter site where they do talk about broken website, which it appears they believe is fixed......https://twitter.com/search?src=typd&q=Calpers%20OptumRx

Anonymous
to Anonymous #1303276

I wish there was a central thread for CalPers members so they could see the problems people are having.If I find a site for feedback to CalPers, I'll post in here.

Meantime you can always go to their Twitter account. They do talk about the website in there, and it looks like they think the problem is fixed @Calpers OptumRx is where I found the info. Hopefully you're able to tweet and let them know in there. Its a train wreck and I suspect will only get worse as people get more frustrated, sick or incapacitated because their medicine was denied by a system that is overwhelmingly burdensome for both the Dr.

and patient to traverse in getting remedy.

Those of us with the time in retirement need to stay on course for our buddies still working, in making this right for everyone.Please don't give up.

Anonymous
to Anonymous #1303281

As civil servants who devoted our lives and careers to caring for Californians...we are very fortunate to have oversight agencies and colleagues who might be able to help us....

and actually themselves as CalPers members.

Here is a place to start:

h t t p://w w w .opa.

ca.gov/Pages/ProblemsAndComplaints_HowToFileAComplaint.aspx

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