If you’ve had to get your own healthcare, then you’ve seen Mountain Health Co-op; the newest addition to the Idaho marketplace. Unfortunately, they are playing an all-too-familiar game with their healthcare coverage that you may have already found upsetting…
It seems like a good deal, their rates are low and the coverage appears to be better than any competitor, but beware the small print; there’s snakes in them thar hills!
So what’s the big deal? Their prescription drug coverage appears to be designed to confuse both the providers and the patients to the degree that the doctor’s office gives up trying and the patient ends up paying full price for medications that are actually covered under their policy.
Such shell games only serve to frustrate and anger those needing regular prescription drugs, and cause supporting staff in at least two offices to throw up their hands and say “We have no idea why they are refusing coverage and we’ve given up.”
Here’s what I’ve found so far from personal experience: Drug coverage appears to be so non-standard, that neither of the St. Luke’s nor St. Alphonsus doctor’s offices I used could navigate the hidden land mines within Mountain Health Co-op’s coverage restrictions. Originally I attempted to work through my doctor’s office, but I was told that they had given up. Then I called the insurance company themselves on several occasions and received conflicting answers both times. OK, this got me riled, especially after having to foot a $200 bill for something that was supposed to only cost $15.
Here’s what I found, along with how to deal with it successfully:
For all coverage options:
There is a blanket cap of 100 pills for any prescription.
You cannot fill the entire prescription and pay for the extra; it’s all or nothing. You either take the 100 pills and miss part of your prescription, or you pay the entire amount.
You will never be reimbursed for paying for it out of your pocket, and none of what you pay counts towards any part of your deductibles or out of pocket cap.
If you opt to take those 100 pills and try to refill when they run out, you will find that Mountain Health Co-op will refuse to honor the prescription refills until the original prescription period runs out. What this means is that if your prescription is for a month of pain meds (for example) and it requires 140 pills for that month, you will end up 40 short if you elect to take the 100 and you will be prevented from obtaining any more until the entire month is up.
Now taken alone, this doesn’t seem like that big a deal, but there are other “Policies” that hinder the process even further. I’ll go over how I finally got the answer and how my doctor’s were finally able to navigate these purpose-built (my opinion) obstructions.
As I mentioned before I did call in several times in order to attempt to clear this up, but the first line of support/defense was not helpful. The following tactic works for nearly any support situation: I insisted upon speaking with a supervisor, and when that supervisor could not give an answer which did not endlessly repeat itself, I insisted upon talking to their supervisor as well. This takes a while, and it does cause some hard feelings, but with a lot of patience and a willingness to repeat yourself endlessly and refuse to back down or hang up the phone, I found out the following:
When you are told you can file for an exception to the 100 pill policy, don’t fall for it; it’s just an administrative step that in their own words, “Has never been approved for as long as I’ve worked here.” So don’t bother spending time with that because it is an administrative roadblock that never ever comes down (by their own admission).
Their support personnel do not know their own product, even their 3rd tier of support were still unable to explain how I could continue getting my prescriptions. After 3 more false starts based on their advice and finding all 3 times that I continued to be denied prescription coverage, I finally got them to put on their Prescription coverage specialist (a subcontractor). Now this was the person in charge of filling the prescriptions themselves and this is where I finally got the answers I needed.
The path through the road blocks: The key is in understanding fully how the following three rules interact with each other and then you can see how to navigate through them. No kidding, I had to walk 4 different people through all of this at my doctor’s office before they caught on and began to follow my instructions and when they did; Wallah! No more prescription denials!
Three rules govern drug coverage:
100 pill per fill cap. No exceptions (even if they offer one, it’s a trap!)
Time limits on refills based upon the time period stated on the prescription.
A restriction on refills based upon the number of pills-per-day prescribed.
How to get around it:
Convince your doctor to prescribe for a shorter period of time. This will cause more prescriptions to be filled more often, (and cause 3 times the paperwork for your doctor’s staff)
Ensure that your doctor is putting down the correct length of time for the shorter prescriptions.
In my case they kept using a template that had “one month” which caused it to be rejected.
Ensure that the “ no refills before [date]” reflects exactly, the number of days it takes to run out based upon the number of pills prescribed per day. If it doesn’t match exactly you could either run out and be without meds for a period of time, or be forced to buy them yourself at full cost. You won’t even get their reduced price either.
There is a 30-day maximum (again no exceptions, don’t even bother trrying) on all prescriptions, so if you are used to getting a 90 day supply, those days are gone.
So: In order to avoid the traps set before you by Mountain Health Co-op, you should
Work with your doctor to cut down your prescriptions to a shorter length of time so that you are filling less than 100 pills
Ensure that no prescriptions exceed a 30 day supply
Ensure that your refill date does not exceed the number of days indicated by the number of pills per day on your prescription. For example if you take 5 pills a day, you can only get a prescription for up to 100 pills for the length of 25 days, at which time you will fill that same prescription again for another 25 days (for ongoing prescriptions).
Keep in mind: No more than 30 days, no more than 100 pills, pills per day must match the exact prescription time period for refills.
This is not how things are normally done, and your doctor’s office will threaten not to do it (mine did twice), but in the end they will do it for you as long as you remain persistent and never back down. It as much as triples the processing time for your doctor’s staff, as well as causing you to do refills up to three times as often, and it serves no purpose other than to save Mountain Health Co-op money at the expense of your doctor, you and a lot of inconvenience.
Not single soul out of the 10 Mountain Health Co-op employees or contractors I spoke with could tell me why these insane restrictions exist.
Personally, it looks to me as if they purposefully depend upon people giving up and paying for their own prescriptions out of sheer frustration with the process. When instituted on a grand scale, this can indeed save them a lot of money; at your expense. To me this shows a level of callous disregard for their covered patients that I’ve never seen before.