A Personal Story: Anthem Blue Cross Profits by Denying Prescriptions

by on January 16, 2014 · 8 comments

in California, Health

drugs prescript moneyIt’s happened again. I have been denied coverage for Modafinil yet again, this time by the exact same company who has already approved it.

I’ve been on a prescription medication that treats my Ideopathic Hypersomnia for several years now. It’s an extremely expensive drug, even the generic form can be more than a $1000 a month. I have been diagnosed by a esteemed sleep doctor in San Diego and he confirms that the drug is both medically necessary and that no effective (and non-narcotic) substitute exists.

Without the drug I suffer from sometimes overwhelming sleepiness. Without it I get a band of sleep deprived headaches, driving may be either impossible or require pulling over to take naps, even after 5 minutes on the road. I grew up with this condition – undiagnosed – and lost years of my life to sleepiness. Smoking cigarettes or eating sugar were the two things I could rely on to help stay awake especially to drive.

I am writing this as I wait on hold for the next patient care advocate with Express Scripts, I am at 43 minutes.

I have grown to believe that this denial is purposeful bureaucratic complexity nurtured to thwart as many people as possible from getting expensive prescribed drugs. I believe this ineptitude within the Health Insurance System, the Pharmacies and the Doctor’s office is actually orchestrated on purpose by Insurance companies to save them money.

Creating a system engineered to make it difficult for the ordinary person to get their prescription paid for is as simple as bringing together enough of the following components; employees without initiative, lack of clear information, information overload, confusion, poor communication lines, information hidden underneath layers of other information, disconcerting medical terms, and allowing the accidental and incorrect information dispersal. .

I am presently at 58 minutes in my time-consuming run around to get the information I need to get my medication. I can’t imagine how I would manage to fight through this labrynthian system if I had a job, had difficulty hearing, had an impairment or, God forbid, was sick or in pain!

It is hard to imagine the CEO and high level directors are unaware that their system keeps their insured from receiving their covered medication.

What caused my present inability to get my prescription filled is that I changed my health insurance from my husband’s Anthem Blue Cross coverage to a different Anthem Blue Cross program. This seems to have given Anthem Blue Cross an excuse to once again deny my medically necessary prescription despite that the drug is listed in a formularly published on the web dated October 2013 (which I checked before signing up) and they have already put me through the very same rigamoral 2 years ago, meaning that they already have everything they need to prove that there is not another form of drug that can help me and that I have the exact diagnosis that this drug is made to treat.

Still, the system has found a way to deny coverage and I have no recourse to go through a series of hoops. My phone just ran at of battery power at 1 hour 13 minutes so I changed phones…

On Monday, The first hoop was my pharmacist at Rite Aid, a cold and disinterested young lady if ever I met one. She was put out when I told her she needed to call my insurance plan after she told me my medication wasn’t covered. She informed me it would “take a long time to get through”. Yeah, well, sorry to make you do your job was what I thought but I kept it to myself.

I returned in an hour and she said that my drug is not on their formulary and it is a closed formulary. I waited for any further information, she had none. Getting more information from her was like ringing water of a dry towel. She did manage told me I could pay for the medication myself but it was expensive (did I mention it cost more than a 1000 a month?).

Next I called and emailed my Doctor, they are notoriously difficult to reach, only in the office from Monday to Thursday, 1 hour lunches and they don’t answer the phone. Left a message.

Called the number on the denial note the pharmacist gave me. Went around and around, three different operators put me through to themselves. That took about 45 minutes. All the information I got was I needed to get my Doctor to call them.

Doctor’s office didn’t call me back or email me any response on Monday, No drug for me, sleepy.

On Tuesday afternoon, I finally heard from my Doctor’s Assistant, she told me she was waiting on-line with the same people I called the day before. She’d been waiting more than an hour. She wanted to know if I had another number to call. I didn’t. Again no modafinil, sleepy. Went to bed at 10:00 pm

Wednesday: Awake at 8, still sleepy. At 8:30 on the telephone with Express Scripts. It is now 10:20am and I’ve talked to Sierra and am waiting to talk to a Supervisor.

Sierra told me that the Doctor’s Office called and initiated a Coverage Review.

The Coverage Review went to the Medical Director. It will take 72 hours for a response.

The response will go directly to my Doctor’s office, not to me. I will be sent a letter.

I’ve learned that I can’t rely on my Doctor to contact me and they are closed on Fridays. So I can either wait for the letter or try to get my friendly neighborhood pharmacy to call for me to see if I have been approved.

If I don’t get approved, well then I can appeal.

Talked with Supervisor after about a 40 minute wait. The conclusion to this is that I will continue to be denied a medically necessary drug because of a inexcusably complex and inefficient bureaucracy, effectively saving the insurance company hundreds of dollars.

So, do they have any reason to improve their system if it saves money? I don’t think so.

{ 8 comments… read them below or add one }

avatar Cape Maynard January 17, 2014 at 12:55 pm

You must have one of those “junk” insurance plans the president has been talking about. Go to get covered California. The plans are affordable and quality. There are also lots of great doctors to choose from and the deductibles are really low. Plus you get free birth control. Win win!


avatar MKS January 17, 2014 at 4:35 pm

Mr. Maynard,
Covered California is precisely where we (my wife who wrote the article) obtained the Anthem Blue Cross policy she is having trouble with. If you did your research before spouting off, you would know they are one of the California eligible plans.
This is also nearly an identical plan to the one she complained about having had the same difficulty with two years ago, and was provided through my employer — by no means one of the “junk” plans you refer to.
And your toting the value of free birth control is simply off base. Maybe its a “win/win” for you, but we don’t need it.


avatar Cape Maynard January 19, 2014 at 11:14 pm

You may not need free birth control but destitute Georgetown law students like Sandra Fluke do. I guess white privilege can only get you so far. But don’t fret. You’re doing your part for women’s health and preventing another republican war on women. You and your wife are paying higher premiums to spread the wealth around to pay for other peep’s mandated FREE stuff. That’s something to feel good about.


avatar Brenda McFarlane January 17, 2014 at 4:42 pm

Yup, wish I could say it was one of those “junk” insurance plans. No, I went with Anthem Blue Cross, Silver. $454 per month. Today I had even more drama, had to take the entire day off to be at home on the landline to accomplish anything. Used both phones. I’ve spent almost 3 hours on the phone with Anthem Blue Cross and now am on the phone with Express Scripts – still waiting at 57 minutes. There was a second issue where they cancelled my policy, no notice. Had to fix that. I’ve got to say that every single person I talked with at both Anthem Blue Cross and Express Scripts was awesome. Friendly and as helpful as they could possibly be given how messed up the system seems to be. Big Kudos to Terry at Anthem Blue Cross and Rochelle at Express Scripts.


avatar Scott January 19, 2014 at 11:36 am


This is an outrageous situation! I’m commenting because a very similar situation occurred to somebody in my family with the identical drug. The insurance company (AETNA) denied the prescription. The patient’s mom works in the insurance industry and I’m a lawyer with some medical experience.

Here’s what we did: after the insurance company denied coverage and the internal corporate fools ratified the decisions, we filed a formal appeal of the decision with the California Insurance Commission. My lawyer letter was the top couple of pages of a big stack of documents with the medical facts of the case and some science on the underlying issues (which were obviously not identical to this case).

The California bureaucracy moves quickly. They granted the independent medical review of the insurance company in less than a month and they overturned the insurance company’s decision altogether in less than a month after that first decision.

The insurance companies make money because most patients do not have the time or staying power to fight. My advice is to persevere. The state is not afraid of the insurance companies and they have the power needed to do what is right.


avatar Terry April 22, 2014 at 4:53 pm

Thank you Brenda McFarlane and commenter Scott for the information you’ve presented here. I found this posting and thread in my search for help in getting my prescriptions refilled.
I, too, have been insured by Anthem Blue Cross for years. Starting on April 1, 2014, I became insured with a Covered California Platinum plan via Anthem Blue Cross. I, too, research which plan was best for me, including prescription drug coverage. I’m writing this comment on April 22, 2014.
I cannot get medications refilled. My medication prescriptions were filled in a 30 day supply, so I have no extra medication to use while Anthem delays/denies coverage. My internist gave to me her entire supply of drug samples of two medications Anthem denied coverage for, but of course, these few samples won’t last long.
These drugs are not to be stopped abruptly. Stopping these drugs abruptly is bad for the body.
I have a number of chronic diseases for which I am treated. I take a number of prescriptions help manage these diseases. Each medication I take has previously been approved by Anthem for my use. This means that each medication I take has previously been pre-approved by a doctor and given the go-ahead for coverage by Anthem staff members.
I live in chronic pain. This pain is daily, in every moment of my life, and has been unceasing for the last 3 years straight. I take multiple medications to reduce the pain, and take no pain relievers. Pain relievers don’t eliminate the pain, cause problems of their own, and are pretty much useless to me.
I take a number of medications to reduce intensity of the daily pain with which I live. I ordered refills of these medications through the usual process. A doctor’s pre-authorization was required by Anthem, and it was made. I eventually learned that Anthem Blue Cross denied coverage. Now Anthem expects me to undertake a grievance process that will take at least 30 days to happen, and Anthem’s answer can still be denial of coverage. What do they suppose I’ll do during those additional 30 days? They couldn’t care less.
The medications Anthem has denied coverage for are just a few of the medications I need. Each medication requires a new pre-authorization from my doctor. Anthem will receive and review these pre-authorizations and decide to deny coverage for all, or nearly all.
In Anthem’s denial of coverage for one pain reducing medication I take, Cymbalta, the optional medications they listed, the medications they want me to take instead of Cymbalta, do not reduce pain. One of the two alternative medications isn’t even in the same class of drugs as Cymbalta.
My doctor shared with me that when she speaks with an Anthem doctor about authorizing the drugs she prescribes for me, she receives yeses. Yes is the answer because the Anthem doctor understands the medicine behind the reason for my taking the drugs prescribed.
How do I circumvent the 30 day grievance process and get straight to my doctor speaking with an Anthem doctor? I am fast running out of my medications.
Had Anthem staff informed me that my prescription medications would not be covered by the Covered California plan I chose (which indicated that these drugs would be covered), and that a lengthy appeals process would be required just to try to get them covered, then I could have tried to get more than the usual 30 day supply of the medications that now need to be refilled.
Anthem Blue Cross has a long history of causing problems in my health insurance coverage, one dropping my coverage because of their accounting error, and dropping my coverage between one insurance plans expiration and the start of another. I got as far as speaking with the Anthem Western Region president, though that did me no good. I received a you’ll-be-getting-a-call from her, but no call was gotten.
So, other Californians on Covered California health insurance, how are you getting your drugs refilled?


avatar Brenda McFarlane April 22, 2014 at 11:28 pm

Terry, Thank you for adding your experience. I did eventually get my prescription drug filled but I suspect publishing my experience helped. A PR representative did try to contact me when they read this article but when I called back did not return my call again. I think we need to use sites like the OB Rag to make sure we are sharing our experiences. When just a few of us complain, we look like it’s us with the problem but when we join our voices together, it is hard for them to deny. I’m so sorry you too are having difficulty. It’s easy for them to make it hard for us to get our medication. They know how difficult it is to fight them and they use it against us in order to profit. It isn’t fair but you have to spend all your time fighting them. The truth is, so many don’t or can’t fight but if you do, and do it smart, you will often be successful. I suggest make sure you 1) Keep track of all correspondence 2) Get names whenever you talk to someone and write out what they say. 3) Talk to supervisors. 4) Try not to get mad at people you talk to, they are often not fully aware of how the company has fixed it so you can’t get your medication 5) Publish your experiences. 6) Keep at it. Good luck and all my thoughts…


avatar Judy Menacker March 25, 2015 at 4:11 pm

I spent an hour on hold with Anthem. Perhaps they are shooting for the Guinness Book of World Records. Long story short, my heel, arch and ankle started hurting to the degree that every step is painful. Started in Feb and I tried ice, rest, rolling the foot on a bottle of water that I had stuck in the freezer. The limb has lymphedema due to cancer surgery years ago. I had to remove the compression garment due to the pain in the ankle bone. Last Wed I tried to see the orth dr. but next available apt is end of April, so I went to the Ankle and Foot Center where the dr. took xrays and I am exhibiting classic signs of tarsal tunnel syndrome and gave me a script for Lyrica. Dropped off the script at Walgreens Wed night and said I’ll pick it up Thurs a.m. Thurs a.m. Walgreens tells me it needs to be pre-authorized. It is a week later; Anthem decides to deny the Rx. Taking Aleve and opiates does not agree with my intestinal tract. The pain brings me to tears, the sheets can’t touch my foot; I can only wish you karmic justice Anthem. So let me get this, Anthem’s pays its CEO obscene amounts of money at our expense of denying needed service and Rx and is too cheap to spend money to secure your network and gets hacked. The cheesy letter saying we were hacked by sophisticated hackers — sophisticated, really when there was no protection to begin with. What a waste of paper that was. An expat friend who lives in Guatemala can go into a drug store and get any medicine over the counter. A third world country where one can get meds. Imagine that. But don’t you know, we in America have the greatest healthcare system in the world. The real rub is no one is “holding a gun” to these people making them accountable.


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