Thursday, November 16, 2006

United "Healthcare" that's Hard to Swallow

Which would be more cruel?
Finding out your heartburn medicine is no longer covered by your health insurance (thus creating an onslaught of gastric acid), or your blood pressure medication has been dropped from the official formulary (and you can guess the appropriate reaction.)

I have neither ailment.

However, either could develop over the saga of dealing with United Healthcare’s prescription drug plan, which has decided to drop coverage of Nexium last month with little fanfare.

I found out about that when I went on line to re-fill my prescription electronically, and was met with an ominous message:

“Effective September 1, 2006, Nexium (esomeprazole magnesium) may cost you more or may no longer be covered under your pharmacy benefit. Before you fill your next prescription, click on ‘Price a medication’ in the left hand navigation on to check the pricing of your medication or use Savings Advisor to identify lower cost alternatives.”

For those of you who have been through the ordeal of treating reflux or indigestion, you know that not all “alternatives” are realistic. Just as each of us have unique chemical characteristics, so do these medications.
They don’t all work on everyone in the same way.

I called up 365 Well Street, and “Shamiqua” told me that she couldn’t tell me why they stopped covering Nexium on my plan, because I’d been sent a letter explaining it.
That makes total sense.
You can’t tell me the answer to my question because you sent me a letter?

Shamiqua was able to give me the names of five other medications, almost as colorful as her name: Omeprazole, Acifex, Protonix, Prevacid, and Zagaret. She said it was most likely that coverage for Nexium was dropped because it was now available over the counter.
No, it’s not.
According to the CVS pharmacy I checked with, you still have to have a prescription for Nexium.
Shamiqua said, well, I’d just have to talk to United Healthcare.

Undeterred, I called United Healthcare for answers.
My first try resulted in being routed back to Shamiqua's department via electronic phone mail hell, although I didn't wait around to speak to her or one of her sistahs.

(Who ever invented automated phone systems should be shot. United Healthcare’s phone system either offers useless choices, or hangs up on you. The ordeal is guaranteed to produce symptoms worthy of treatment with other prescription drugs.)

So I called the local Houston United Healthcare office. My thinking was, a real, human on the phone could answer my questions, or at least direct me to a better source.
Not so.
The woman was nice, but clueless.

She routed me to United Healthcare’s HR department, with an electronic phone prompt which refused to budge until I gave them an employee number. Not having such, I outwitted the phone system by outwaiting it, and was routed to another live person…who gave me the number to United Healthcare’s corporate offices (which was not available on their website, by the way; I'd checked that first.)

I dialed Corporate’s toll-free number, and told the real, live operator I needed to speak with the person who makes the decisions on which drugs are covered and which are not covered by their prescription plan.

“You need Formulary,” she said, and rang me through to—you guessed it—another voice mail.

Are you keeping up? Three different calls to three different numbers, so far.

The voice mail identified it’s owner as Joe Stahl, who was out, but would return my call shortly, if only I would leave my name and number.
I did.
He didn’t.

So I called back later in the day.
Joe has an assistant, Nicole, who’s voice mail also kicked in to capture my message in crisp, digital sound.
She’d call me back.
She hasn’t.

Last night I received an e-mail from United Healthcare, with the same nebulous, benumbed response I’d gotten during the day, telling me that I could “purchase this medication locally at 100% of the price off-plan.”

Duh. Ya’ think?

The only think more troubling than the insipid, bureaucratic mindlessness these companies exhibit is the insulting, condescending tone they take with their customers.

Here’s the deal.
United Healthcare is in business to make money, not provide you with quality healthcare. That they do most of the time is incidental; don’t be fooled. They’re in business to make money.

Through the process of elimination, United Healthcare has decided that the best medications to take are those that cost the least, not necessarily those compounds which might work the best.

That’s why instead of Nexium, I can either buy something over the counter, or ask for a prescription for something that sounds like you could name your next child.

Too bad the bean counters at the insurance companies know better how to treat me than my doctor. All that education in medical school must have been just a waste of time and money.

If you want to practice medicine, just become an accountant for a health care provider.


Ray said...

Try "staterra"."Respidol","and"
"clonidine" for an autistic 10 year old we have. Blue Cross Blue Shield (which Rick Perry gave the Teachers of Texas) have squawked and will deny covering at times. Their third world customer service agents are wonderful.:(

Anonymous said...

The medical insurance profession is going to have no one to blame but themselves when the public outcry is such that the Gov't is forced to regulate (and subsidize) the medical industry.

Oh they'll holler about "free markets" and "the American Way" and all that, conveniently ignoring that the "Americn Way meme" originally involved some semblance of community responsibility.

Of course, one of the great fights in America has been to balance the needs of the community with the needs of the market. This time the community may win due to the stupidity of the market.

Anonymous said...

I see nowhere in your rant on Nexium is a conversation with, say, a Pharmacist mentioned. Since your real problem is UHC is forcing mail order through financial blackmail (by the way, a lower copay does not necessarily mean a lower price of the drug- the copay is a totally artificial price made up by UHC) I assume you never talk to a Pharmacist. If you did we (I am a Pharmacist) could explain this to you. Merck came out with Prilosec years ago. I was a therapeutic breakthrough and worth the high price they were charging for it. When their patent came close to expiring, Merck miraculously came up with a "new and improved" Prilosec called Nexium. In actuality, Prilosec was a combination of left and right handed molecules (called isomers) only one of which was active. This is common in nature. Merck separated the isomers, took the active one only and marketed it as Nexium. NOTE: Prilosec's most common dosage is 20mg. Nexium's most common dosage is 40mg. If in Prilosec 1/2 of the mg was inactive Prilsec 20mg should be (and is) exactly equal to Nexium 10mg. But Merck marketed Nexium as 40mg. FOUR times the dosage. Oddly enough, it worked better.
The conclusion: Nexium is a rip off. It is exactly the same as Prilosec as 1/2 of Prilosec is inactive. The active 1/2 of Prilosec is marketed as Nexium by the exact same company.
Doctors get most of their information from Drug Reps. Drug Reps fail to mention most of this information.
Now, I consider insurances the devil incarnate. Not a big fan. But the main problem is they are removing the Pharmacist from the equation and you need the Pharmacist. A good Pharmacist can explain a lot, but the main thing is they watch out for your health. Medicines are not the same as laundry soap although most of America and I know Wal-Mart feel differently.
But there is plenty of blame to go around. In this case the Drug Manufacturers are gouging the consumer. The consumer is UHC and UHC is in a position to fight back (you are a consumer of UHC only secondarily the Drug Manuf.) UHC is acutely familiar with the Prilosec/Nexium ripoff and is correct in making you get the cheapest equivalent therapy available. You would be first in line criticizing any increase in premiums. And, seriously, all the drugs in that category are the same no matter what you say.

Brent Clanton said...

I did have a brief exchange with a Pharmacist from the local CVS store, but she did not go into the detail that you did here. Excellent information--thanks for the inside scoop!

Anonymous said...

I did talk to a pharmacist at UHC, his answer was " I don't know why they don't cover nexium, it's not our decision". And having gone the prilosec route, I can guarantee nexium works better for me. I will be buying it over the counter and changing insurances starting next year.

Anonymous said...

Yes, the actual information about what Nexium actually is in comparison to Prilosec is nice, but "four times the dosage" was actually the only drug that helped control my acid issues. So instead of having Nexium, I'm forced to consider taking four Prilosec OTC pills per day?

Anonymous said...

I too have United Healthcare and my particular plan covered it up until 1/1. Now I am searching for a replacement, meanwhile I am miserable. They gave me the list of alternate drugs, however would not cover any of them at the same strength except for Protonix. Which is $128 per bottle versus $150 per bottle for Nexium. The Protonix is not working. It comes down to Drug companies, Hospitals and Drs charging ridiculous prices (look at the break down of a hospital bill $10 for a box of tissues?)So then the insurance companies bite back and either don't cover things or at a very reduced price. In the end, its all of us who get screwed.

David said...

Thanks for letting me know I am not alone! If anyone wants to pursue the Nexium Matter, I am currently at battle with UHC regarding this sudden "DENIAL" of Nexium. I am on my 3rd required appeal to UHC to cover this medication. I am going the distance on this issue because I feel the Insurance Industry has too much control over my life. They are REQUIRED to observe the "Standard of Care" just as doctors are. When they drop a successful medication "a working one”, they inflict unnecessary Pain and Suffering. They pretend to practice medicine, when they WERE PAYING FOR THE MEDICATION TO A POSITIVE OUTCOME. Now I will need surgery to correct the problem since NONE OF THE OTHER MEDICATIONS ARE HELPING. So, Who do you think will pay for this? You guessed it UHC! They will not pay for Nexium, but they WILL pay for Surgery to fix GERD. When I have filed all the appeals and cut all the red tape, I will be filing a Class Action Application to the US Federal Courts to force UHC to cover the Nexium for those of us who had POSITIVE RESULTS with Nexium. If you want to contact me with your name and information to add to a Class Action Law Suit here is my email:

jimmcc said...

The information from the Pharmacist - this is GREAT information. It's hard to see who the bad guy is: UHC or Merck. Several years ago I started taking Prilosec... it didn't work. Then my doctor prescribed Prevacid... it didn't work. Nexium... IT WORKED! That was several years ago and I have had no problems while on Nexium.

Well, guess what? I just got a new job and their insurance is through UHC! I just found out today that Nexium is not covered (even with a doctor pre-auth). I have not taken Acifex yet but the doctor has called me in the Rx. Question to the Pharmacist: Is Acifex and Nexium the same in dosage/strength? Is there any other info you can tell us about Acifex? Thanks for your work!

Anonymous said...

I know this post is old, but I just had to comment. My wife is a health care provider. You think it is difficult talking to United Healthcare? It is 100 times harder dealing with them when you are trying to get paid for services rendered to one of their customers. They use all kinds of delay tactics. Your comment about their phone system really hit home here.

Edward M. said...

UHC just doesn't pay. My father-in-law has run up over $85,000 dollars in his end-state renal care. UNC is obligated by Federal Law to pay, but they just won't pay. They don't answer letters. They don't do what they say on the phone. They don't answer the phones in a timely manner. They will not recognize their obligation under the law. This experience has made completely in favor of NATIONAL SOCIALIZED MEDICINE as the only alternative to this b.s. Anyone who says that the private sector is good at providing health care is an idiot. Health care in the United States has degenerated into a profit-making racket in which innocent people get killed while executives who are little more than criminals put the money in the bank. I want it all shut down. All of it. One national data center with a single file of medical records for each person. One set of policies that everyone understands. One set of rules that everyone can live by.

Anonymous said...

So I went to the doctor today for diagnosis of this terrible feeling I've had in my chest/throat for the past 6 weeks. I was told I have acid reflux disease. No problem, I thought, as I was given a prescription and sent on my way. I went to pick up my medication a while ago only to discover that my insurance, UHC, doesn't cover it. WHAT?????? $187???? For a 30 day supply? WHAT??? Oh yes, I will fight this.

Anonymous said...

If you have the facts on your side the argue the facts, if you don't then just complain about the big bad insurance company. The issue is that chemically, Prilosec has two isomers of same agent. omeprazole and esomeprazole in equal proportions. Astra Zeneca figures out a way to cleave out esomeprazole from the compound put it in a capsule, spray paint it purple, put three gold bands around it and through direct to consumer marketing convince people with no medical knowledge that it's the only thing for you that works. Chemically, every tablet of Prilosec is 50% Nexium. Nexium is 8-10x the price with no medical evidence that it works any better than Prilosec. Why would it? it's chemically the same coumpound in all the ways that matter. Why should you care? Because your employer foots the bill and every time they spend 150-200 bucks a crack for a drug with no proven advantage over other Proton Pump Inhibitors, that's money that they don't have for your salary increase or whatever else you feel that you are entitled to. Health care spend in America is out of control, be part of the solution and stop whining like a girl. Or better still, stop smoking and put down the the coffee. Your reflux will go away and you won't need to take anything

Anonymous said...

After we elect Obama, he will appoint Senator Hilary Clinton as the Secretary of Health, Education and Welfare and, at the least, health care and managed care providers can expect to be regulated and monitored as they now do us :)

Healthcare said...

I think a system similar to the NHS in the UK would be a good thing for the US it will help reduce ridiculously over prices drugs.

Jane said...

I've never heard your radio show before, but I'm just wondering if your rants on the air sound as racist as this one does.

I stumbled across your site while doing research for a biochemistry project on Nexium. I'm looking for information on insurance company coverage of this medicine.

After learning about how Nexium is virtually identical to Prilosec (non-technically, the difference is Nexium is about twice as strong mg to mg), I'm happy to hear that insurance companies are dropping coverage of it.

The cost of healthcare is exorbitant in this country because of the pharmaceutical industry that "develops" countless drugs that are nothing but generic drugs in new clothing that then get aggressively marketed to doctors by "friendly" drug reps with fist-fulls of samples, just like the corner pusher gives to new addicts.

If more insurance companies followed suit, we just might be able to claw our way back from being 37th in quality (among industrialized nations) and 1st in spending.

I would be surprised to see my comment posted. It would be enough to know that you read these words and at least for the few moments it took, you heard a different perspective.

And please try to sound less racist. Thanks!

Brent Clanton said...


Surprise--I posted your comment.

You need to grow a thicker hide. There is NOTHING racist about this blog post, so please do not try to take issue with my comments where there is none.

Good luck on your BioChem project, and thanks for stopping by.


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