When insurance companies decide a drug is being overprescribed


But with the easiest savings already in the past, OptumRx and rivals such as CVS Health and Express Scripts have begun mining their huge troves of prescription data in search of economies…

UnitedHealth began laying the groundwork for the data push in 2011, when it grouped an array of businesses under the Optum brand. In a recent case, the company noticed that at one client, drugs for attention deficit hyperactivity disorder were being overprescribed to adults. Some were using the drug to improve their performance at work, according to Andrea Marks, chief analytics officer at OptumRx. The benefit manager took action, saving the 19,000-worker company $110,000…

For chronic pain patients, you’ll see insurance companies limiting the type and amount of prescription drugs you’re allowed to use for treatment. And they’ll use the new CDC rules to support their decisions.

You can always appeal any decision like this, but it will involve patience, time, and probably paying your doctor to document your need for the treatment. Most of the stories I’ve read about appeals have been favorable for the patient, but be prepared for a fight.

Sumit Dutta, OptumRx’s chief medical officer, says the company makes sure its coverage decisions are medically appropriate. “All of those have to be vetted clinically first,” he says. “You can’t say one drug is favored over another drug unless you’ve fully vetted that clinically.” …

To favor one drug over another is discriminating against the patient population that will achieve a benefit from the non-favored drug. But then, when all you care about is making money, you don’t really care about discrimination.

I’ve done some reading about the history of health insurance companies, and maybe we needed them in the past, but we really don’t need them now. It’s just one more layer of clueless people telling patients which services and medications they’re allowed to have access to, while we’re the ones paying for this intermediary.

One of the reasons our health care is so expensive is because we’re paying for the whole insurance industry to be involved with our medical decisions. Funny, but it was doctors who created the health care insurance industry, and now it’s the industry that’s helping to financially destroy doctors. I believe that’s called irony, and on quite a large scale.


9 thoughts on “When insurance companies decide a drug is being overprescribed

  1. Too funny you write about that….I just spent over a week getting my doctor, my pharmacy, and my insurance to all talk to each other so I could be prescribed Lidoderm patches!

    Liked by 3 people

  2. I have some old Lidoderm patches at home that the dr gave me a long time ago didn’t get deep enough for me but the main thing I wanted to say was I seen a tv commercial that is over the counter lidoderm patches with some other medication in it or it just might be the patch..just wanted to share so you could maybe look and would not have to go thru fucking hell to get medication…
    Speaking of medication no fucking medication the medication cream I need for my lupus face my insurance used to cover it and I haven’t had to fill it in a year or so ..well they won’t cover it and my dr is pissed the fuck off!!..it was going to be over 252.00 for a tube of cream 15grams a small fucking tube…I do have some left from last lupus rash flare but this was different cream than the other lol..they covered that but I needed to be on something stronger since the forms of lupus I have is more advance and aggressive so fuck insurance companies …I don’t have the energy to fight them and have the dr call them since every single time that I have done that even with the dr stating that suzette needs this for what ever and blah blah not once have they given in …so fuck them fuck them…

    Liked by 1 person

    • I’ve seen some over-the-counter pain patches that have lidocaine, but I’m sure the percentage of lidocaine in these patches is very small.

      Usually, what the insurance company wants to see is that you’ve tried all the other cheaper medications before they’ll agree to cover the more expensive ones. So, you just need to document which medications you’ve used to treat the rash (and Lupus) and how long they were effective. Then, your doctor just needs to write a cover letter. You might as well try, as it looks like you don’t have too many options.

      Just take a deep breath… and get it done. (I should take my own advice.) 🙂

      Liked by 2 people

      • Hey gurly gurl!!!
        I am sure that your on point with the amount of medication in them for sure..
        No I don’t have to many options on the creams at all I think there might be one more they can give me and I have an older tube of that as well..This one she wanted me on is not making any headway on my face and neck…but I will give it more time and see how it works out then if I still look pretty bad I will try the other but will have to check with her the doc first ..but Tuesday I will let the doc office know about what is going on and you are right at least try..gurl just tired that is all..it seems like it is always something..I know you understand that my dear one… ; )
        lol I am tired of us ill people having to do all the work ..all the calls all the other peoples jobs that they are getting paid to work but we end up doing..that is another gripe I have lolol…OK DEEP,DEEP BREATH ….trying to make the best of a rough morning but it is getting better ; )
        So what if any plans do you have for this wonderful loud 4th of July?? lol anything special going on gurl???

        Liked by 1 person

        • It doesn’t really matter if it’s a holiday or the weekend, every day is about the same in my life, so I haven’t planned anything special for July 4th. Hard to celebrate independence when I’m not feeling very independent. I’m beginning to think that I’m going to have to grow my own bud if I really want to be independent. An expensive endeavor that would take a lot of work…

          DEEP BREATHS… 🙂

          Liked by 1 person

        • Same here gurl..another day…nothing to get to excited over lol…I understand what your saying too..
          There has to be someone gurl…maybe you looking in the wrong place lol.. I wish that I could help you out but me not that kind of smoker lol as of yet lol..
          I am sure that you can find someone a good source just takes time your still in a new area and shitt..Just be safe looking for some..

          Liked by 1 person

  3. The last two paragraphs of your post say it all and say it well. The only possible justification I can see for that “layer of clueless people” is the possibility that some afflicted people don’t have a clue how to proceed and need direction….which is all the more reason why sufferers need to educate themselves as much as possible so as to take control of their own care and not to be at the mercy of the insurance industry.

    Liked by 1 person

  4. “It’s just one more layer of clueless people telling patients which services and medications they’re allowed to have access to, while we’re the ones paying for this intermediary” – so true. It drives me insane. And they often only cover the most expensive med and co-payment top-up falls to our shoulders

    Liked by 1 person

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