A Personal Story: Anthem Blue Cross Profits by Denying Prescriptions

by on January 16, 2014 · 19 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.

{ 19 comments… read them below or add one }

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!


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.


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.


Jesus July 18, 2018 at 1:37 pm

Jesus says stop typing


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.


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.


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?


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…


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.


Luke February 27, 2016 at 8:05 pm

I just happend to notice the last entry in regards to this thread was almost a year ago. Just want to let everyone know that the DRAMA is ongoing with Blue Cross and Express scripts. To this day they use what ever excuse they can find to keep you from getting your meds. Ive been going through the same B.S. To make a long story short, they put me through the non working generic run around that put me at risk of a stroke. They took me off of an already approved Rx. That all occurred 3 months ago when I was trying to secure my 90 day supply. It took 21 emails 8 separate phone calls and a total of 17 days until I finally received my Rx. I was 6 days without meds. Even though they told me they put in an emergency voucher at my local pharmacy for meds to cover the days Im out. Non of that happen as I was put at risk of stroke by my Dr and shipped off to the emergency room. Now here I am 3 months later all medications are approved they have a credit card on file. I put my order in on Feb 18th 2016. It is now Feb 27 2016. There excuse this time. They are saying they need to speak to me about the payment????? I made several attempts to call them but you can never get through to them. When I finally spoke to someone they put me through the same BS about having an emergency care pkg from my local pharm to hold me over. Again non of that happen. Once again Im at risk and will be going to the emergency room. My order is still in pending even though they have a green lite to ship.


Colin February 29, 2016 at 8:18 am

Ugh. Just wanted to offer my sympathies, human to fellow human. The scourge of for-profit healthcare makes the term “healthcare” an oxymoron. Hopefully one day the mass rank and file will stop voting for politicians who deny the commonsense healthcare economics of federal single payer, i.e., expanded Medicare for all, one huge risk pool where we all each pay a little every month (and much less than for private market insurance premiums) into a taxpayer funded national healthcare insurance program run not for profit but instead for providing much more comprehensive healthcare. When will people wake up and stop believing they need to pay more pennies on the dollar for private insurance profits than for their own self interest. The “socialized” medicine health”scare” propaganda tactic is an antiquated throwback to mid 20c. “Red Scare” hysteria. But it’s worked for an entire generation of self-defeating voters. Let’s hope the younger generation is smart enough to vote for spending their money on their own healthcare and not on insurance executives’ multiple mansions. But, alas, a vote for Hillary is yet another vote for the latest and greatest in healthcare, the high deductibles of Obamacare and the business as usual individual consumer losing battles with the giant insurance companies trying to kill us for their stockholders’ purses.


Luke February 29, 2016 at 6:51 pm

Update. It is now Feb 29th. Im still with out medication. BCBS/express scripts called me from St Louis. It was a rep from there social media group. They obviously read my posting from the 27th. They said they want to resolve this matter. There solution to this was telling me they have to get an ok from my Dr???? Why do you need to get with my Dr. they have done there part all Rx are in active status. The Pharmacy is waiting for a call from you all authorizing 7 days at no cost to me. They couldnt give me a direct answer about that and kept saying they will call my Dr. About 40 mins went by and they called me back saying they spoke with my Dr and care package is ready to go at CVS. also said it would be around 3 to 7 days to get an ok for my order. These people must think their customers are absolute morons. I spoke with my Drs office THEY RECIEVED NO CALLS ABOUT THIS. Spoke with my local pharm NO CALLS TO THEM EITHER. When you people from your social media see this. DO NOT CALL ME. I dont have the time nor do I care to be continually lied to, nothing but empty promises. FYI my Dr did tell me that they dont understand why BCBS have to speak to them about this they should be calling drug store…….nothing but wrongful acts and delay tactics. Again this has been going on since Feb 18th and it looks like this will be going well past 2 weeks and still no meds and no physical proof as to why other than a new excuse everytime contact is established. I even have an agent involved and you all have done nothing but lie to her as well. I can just imagine how many poor soles out there have become victims of your wrong doings or worse yet have DIED. Oh one other thing it doesnt help to take names of who you spoke to you never ever get to speak with the same person about matters ever. This is pretty SAD. All RXs are just sitting with active status. You all have my credit card on file that is approved. Ive got money in my bank to pay for my meds. still you people find the most pathetic reasons to stall shipment. My Drs are very upset having to here about this. Its pretty sad that I may have to take legal action just because this firm insist on putting many of us through childish games. Children have an excuse because they may not know they are being wrong. Im supposed to be dealing with adults. Instead im talking to people more concerned about lining their pockets. This is so wrongful, sad thing is you all know its wrong. Their is no way in HELL you people can be all right with what your doing to your customers. But money is powerful Im sure thats the prime motivator. My agent had no clue that this was going on at first she thought I was just being one of those hard to lease people. Thats all changed now that she got to experience and find out that everything I told her is true. You all lied to her as well.


Lauren August 15, 2016 at 5:39 pm

The above are the similar versions of my story.

After receiving a prior authorization APPROVED BY ANTHEM, every month it’s a fight (‘nightmare’ is a better word). Once, I waited until the 37th day to get my 30-day supply. And every month it’s a different reason from a different Anthem rep. One said “it says you exceeded plan limits”, one said it hadn’t been 30 days, one said the benefits of my plan changed, one said I was trying to obtain a 60-day supply instead of a 30-day supply. None of these excuses were true.

I do believe that Anthem tries to maximize profits by hoping those of us who are ill are to sick to fight. So we pay the cash price. I have paid cash 3 of the last 6 or 7 months – even though I have not tried to pick up early, and, as mentioned I have an approved prior authorization.

Another concern: every disaster preparedness group recommends having an extra week or more of medication on hand. How is that possible when companies like Anthem makes patients wait well beyond their prescription due dates ? I pray a disaster doesn’t occur when I’m down to my last 1/2 pill and have been arguing with Anthem/Express Scripts for days. One would hope there is a ‘hungry’ class-action attorney reading these posts. Best wishes to all – Lauren


Nicole March 8, 2017 at 6:19 pm

I know that this is 6 months after the last post, but having the same issue. Needed a pre-certification at the beginning of my plan year (feb.1st) for a medication I have used since 2009 and that Anthem covered for the exact same diagnosis, at the same dosage, on the exact same plan, prescribed by the same doctor last year. Being denied this year because, according to Anthem, a different diagnosis code was used on this year’s pre-cert form. So after many phone calls back and forth between doctor’s office and Anthem, it is actually the same diagnosis code. I have tried 8 other medications, from Adderall and Ritalin, to Provigil and they do not work. Vyvanse has been a God-send for me, but now it is no longer covered. So while everyone is trying to have me wait for the denial letter, to waiting for the doctor to review the case, to figuring out what to do, I am struggling with falling asleep while working, falling asleep while driving and being so incredibly tired I can barely stay awake to spend time with my 4 year old son.


Curt March 16, 2017 at 2:35 pm

Oh how I know this issue. In December I needed a medication called Daytrana, and there were shortages, so to deal with that, I tried to get my doctor to prescribe concerta. Doctor wasn’t thinking about the whole insurance crap and the end of year challenges and prescribed a new chewable tablet for ADHD. Anyway, picked up the script for that which means I had to drive an hour to get to the doctor, then an hour back to the pharmacy. No one would fill out the prior authorization even though I knew it was needed. So, get to the pharmacy they try to fill it, and then am told a few days later they cant fill it because what do you know it needed a prior authorization, well get them to contact my doctor after a few tries since they had the wrong number. A week passes and then i find out that the prior authorization had the medication changed to methylphenedate by Anthem to a non chewable variant so then the prescription is useless. Again I already predicted that back in December. So I had to go back to the doctor an hour away since they don’t have an electronic means to send it. So, now finally i can get the medication filled at the pharmacy a few days later. All in it took a month to get my medication filled. I was lucky I had been rationing my Daytrana patch.
Now March comes along and now the pharmacy tells me when I get there 2 days after having filled it that oh, it says I was going to pay in cash. NO NO NO NO. I have insurance and I want it billed to the insurance. What the heck! Find out that it needs a new prior authorization for some stupid reason and Now I am out of meds since I have no ability to ration it and the various requirements from working and pharmacy only fills it 2 days prior to being out, I run out. Called my dr to try to get them to push to get the new prior authorization. They work on it, call next day find out that they couldn’t get it to go through the normal web portal system and that they would have to call. Still out of medication and trying to figure out how to make this system move faster since I am in a rush now and I will not pay for medication out right. I have done so in the past and Anthem owes me over a thousand dollars that I haven’t requested since they won’t do it without a real struggle. I really want to hunt down the people that make these decisions. It isn’t fair, we pay our insurance yet they do nothing to help us. And I am not on a cheap plan. Not even close. No one should have to wait a week let alone a month to get the medications that have been prescribed to them. I will be calling the insurance commission tomorrow if I don’t get any help today. So frustrating.


BRENDA MCFARLANE March 16, 2017 at 9:09 pm

I am so pleased that people keep posting. It is so important to keep letting others know that this isn’t just happening to you but many many of us. They prey on our sense that maybe we’re doing something wrong and our shame for needing medication. In this way they save so much money. They try to blame and confuse. So many of us simply don’t have the time to even fight the system we just give up so we can focus on our jobs and family commitments. They know how busy we are and count on their ability to out man us and out stay us. It’s very tough and so wasteful but those if us who have the determination really make a difference for those overwhelmed with the regular demands of surviving this world.


Reid September 19, 2017 at 2:35 pm

I have been denied yet again for prescriptions with Anthem they give no reason they just deny it. Scripts I have been on for years now when they are refilled are denied. I call them they say the doctor has to call to get authorization now, the doctor calls they deny is again.


Luke July 18, 2018 at 2:49 pm

Anthem Blue cross is a scam insurance program. I got rid of them and what a pleasure it is to deal with my me coverage. Sierra heath plan works very well. No waiting forever to speak to some one and when you do you actually get answers and things actually happen. ANTHEM BLUE CROSS SUCKS. LOW LIFE SUCKING SCUM BAGS.


Brenda McFarlane July 8, 2019 at 11:47 pm

Things were going well for awhile. I moved out of state, didn’t make enough money to qualify for Obamacare so got Medicaid. Wow! Incredibly helpful. Medicaid finances private insurers. Molina was dealing wih me pretty well and honestly and then they dropped out of New Mexico. Well, this January I had to switch to… ugh! Blue Cross Blue Shield New Mexico. I still have the medical condition Idiopathic Hypersomnia. Still need Modafinil to function like a normal person. Still costs a fortune. But BCBSNM takes underhanded delay tactics to a WHOLE new level. They denied. I appealed. I won. I got my medication. I relaxed. I go back the next month. Medication is denied. Turns out what I won was one single month of medication (that I will probably need the rest of my life and my appeal said so). I look at the letter they sent to me and you wouldn’t believe it. The first page is clear, they overturned their denial. On the back second page however they sneak in this sentence :”We will approve Modafinil 200 milligrams [sic] tablets for one month from July 7th, 2019 through June 7, 2019.” It did strike me as odd to be specific like that but I couldn’t fathom that my 8 page appeal would be responded to by only being granted one month of medication. Plus, if they had meant that, I reasoned, they would have pointed that fact out, right? They would have mentioned it being just for one month and that I’d need to re-appeal if I wanted the medication for longer, right? Apparently not. See, by being unclear they bought themselves weeks, even months of time they don’t have to pay for my medication because I missed the deadline for a Fair Hearing with the NM Insurance Commission. I only had 30 days and they tricked me into relaxing and thinking things were resolved so that my opportunity would expire. Very clever, and very wrong. And even though I think I can still get my fair hearing, BCBSNM suffers no consequences for their unethical tactics, while I suffer months without my medication. For BCBSNM, this is a win win. If I eventually get my medication, they’ve saved hundreds by delaying me for months. If I give up, if they exhaust my resources, they save thousands. What penalty do they pay in America for conning and tricking people? None. More updates to follow.


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