Complaints

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  RX Preferred Benefits

  2520 N Mt. Juliet Road Mount Juliet, TN 37122

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  RX Preferred Benefits

  PO Box 396 Mount Juliet, TN 37121-0396

The complaint text that is displayed might not represent all complaints filed with BBB. Some consumers may elect to not publish the details of their complaints, some complaints may not meet BBB's standards for publication, or BBB may display a portion of complaints when a high volume is received for a particular business.

• Initial Complaint

  Date:09/26/2024

  Type:Service or Repair Issues
  Status:

  ResolvedMore info

  Complaint statuses

  Resolved:

  The complainant verified the issue was resolved to their satisfaction.

  Unresolved:

  The business responded to the dispute but failed to make a good faith effort to resolve it.

  Answered:

  The business addressed the issues within the complaint, but the consumer either a) did not accept the response, OR b) did not notify BBB as to their satisfaction.

  Unanswered:

  The business failed to respond to the dispute.

  Unpursuable:

  BBB is unable to locate the business.

  This is my second complaint regarding *** this year regarding failure to authorize a prescription AFTER proper documentation has been submitted. My MD prescribed two medications (*******-which I have been on for several years and ******* which is a new medication that I needed to start. My previous antidepressant (**********) was discontinued because I could not get authorization from this same company earlier this year and I chose to pay out of pocket. I had also been on ********** for several years. I no longer can afford to pay out of pocket for my prescriptions other than the co-pay; this is why I continue to work. The pre-authorizations were submitted on or around 9/4 per my PCP's office. I have now spoken with the pharmacy on 3 separate occasions and it is still listed as requiring pre-authorization. I spoke with someone from *** this morning and I had a VERY difficulty time understanding him. after approximately ***** minutes on the phone he told me he would have to transfer my call to someone else (I think). I could not understand the reason and I had to go back to work to make rounds.Why is this such an issue? Why can't this be fixed? Why can't this be handled in a timely manner? I realize it is the job of *** to deny everything possible to save the facility money however that is not good and prudent care. I make my payments and I pay my co-pays in a timely manner . They should respond in kind. By the way, I am over 65 years old so technically a senior citizen.

  Business Response

  Date: 10/04/2024

  We have documented the following regarding the plan member and this complaint. I am suspicious that she believes the medication is not covered due to having a $200 copay. The pharmacy has reversed each paid claim received for **********. Additionally, the pharmacy has not entered the PA number on the most recent attempts, so the claims have been rejecting.
  
  (**********) A prior authorization request was started for the medication that the member stated was a continuation on 04/05/24. We sent three request attempts to the provider, but despite our efforts, no documents were received. The request was denied on 04/12/24.
  
  The plan emailed and asked that we reopen the request on 04/29/24. The request was reopened the same day.We called the provider, verbally requested supporting documents, and sent another request via fax. We called the providers office again on 04/30/24 and provided another verbal request as we still had not received the supporting documents. The providers office said they would send the documents, but they just had not had the time to do so yet. We received the supporting documents on 05/01/24. The records were reviewed on the same day, and approval was given to the pharmacy. The pharmacy reversed the paid claim and every other paid claim they received for this medication. The most recent claims being run for this medication have been rejected due to the pharmacy not entering the Prior Authorization number. We have called the pharmacy to remind them the Prior Authorization approval number must be entered for every fill. We will also contact the member to tell her that a copay card is available to help with her portion of the financial responsibility if she feels her copay is unaffordable.
  
  (******* & *******) Prior authorization requests were started on 09/14/24 for both of the other medications the member mentioned. Both requests were denied on 09/21/24 after three attempts at receiving supporting documentation with no results. Both requests were reopened on 09/24/24. We called the providers office to make a verbal request and ensure they knew what was needed for review. These requests are still open, and we are still waiting for supporting documentation to be submitted to our clinical team for review.

  Finally, RxPreferrd Benefits was able to get in touch with the member. We explained that ********** has approval on file, and the pharmacy needs to enter the Prior Authorization number for each fill. The member said her provider took her off ********** because they thought it had been denied, and she is now trying to get ******* approved. We told the member that we were working on the PA for this medication and that we were waiting for the supporting records. We called the provider again to request supporting documents. We have only received the Prior Authorization form at this time. We are still waiting on the provider. 

  Customer Answer

  Date: 10/05/2024

   
  Complaint: 22308618
  
  I am rejecting this response because: 1) I have spoken with my providers office and was advised they had sent the correct paperwork again. 2) You have received some kind of paperwork because I was notified my ******* was denied due to not going through the step process. I am on ******* precisely because I HAVE tried everything else over the 45+ years I have had migraines and nothing else works to date. I can no longer take triptans because of the type of migraines I get. I hallucinate with ****. I cannot take beta blockers because I have asthma. Ergotamine is out of the question due to the trip of migraine. ***** gives me neck spasms. We are down to this new class of drugs or nasal narcotics and I still work full time and need to be able to function. 
  With regards to the **********, I have been registered nurse for 43 years and am well aware of the cost of a copay. I was told repeatedly that it had not been authorized by the pharmacy and the manufacturers coupon was not recognized if my private insurance would not pay first. 
  Do better. I have done my part.
  
  Sincerely,
  
  **** *******

  Business Response

  Date: 10/09/2024

  RxPreferred Benefits did not receive the provider's office notes for ******* until 10/01/24. Upon receipt, the request was denied due to Step Therapy. However RxPreferred has reviewed the documents received and feel approval is appropriate. The RxPreferred team has been asked to approve it. From the documents received, the member does not meet Step Therapy for the *******. The provider's office will be called again to relay this information and to ask if they have sent all previously tried and failed medications. Once we speak with the provider regarding the ******* and once the pharmacy has a paid claim for the *******, we will call the member again to provide an update. 

  Customer Answer

  Date: 10/09/2024

   
  Complaint: 22308618
  
  I am rejecting this response because: I have only been with this PCP for a little over a year. I have been on antidepressants since 1987. This includes TCAs, SSRI and SNRI as well as the newer class to include **********. I tolerate each for a certain length of time and then seem to develop a tolerance to it and the med gets changed to a different one. 
  As previously communicated , the fact that the ********** was approved was never conveyed to me which is why I was taken off of it. I have been on sertraline before but he had to try something. The ******* is NOT a replacement. It is in hopes to boost the sertraline which quit working in the past. 
  Thank you for agreeing to the ******* however. I will wait to hear from you officially before I try to fill it.
  
  Sincerely,
  
  **** *******

  Business Response

  Date: 10/30/2024

  ****,

  We are unsure what you mean about "waiting to hear from us officially regarding the *******", as our team member called you on 10/10/24 and spoke directly with you regarding this. We typically do not contact members to relay approval/denial however, we do send a letter to the members prescriber. We have included our team member's note from the call below on 10/10/***** for the *******, you currently do not meet Step Therapy according to the documents submitted by your prescriber. There is a section on the Prior Authorization request form where the prescriber can list all tried and failed medications (following the step therapy rules), and the provider noted that the member had tried no first-line treatments, which is what we need to determine if Step Therapy has been met. On 10/09/24, we also called the prescribers office and spoke with a nurse named ****** to relay why the request was denied.  
  

  Notes from the call.
  10/10/24 - I called the member to let her know we did approve the ******* and the pharmacy should reach out when ready for pick up. Please see details box for the *******. I let her know that we denied the ******* for a lack of Step Therapy and we let her provider's office know what she needed to try before this could be approved. She stated that she has been on an antidepressant medication since 1987 and the doctor will not have proof of all the medications she has taken. I let her know that the doctor sent us all the tried and failed medications and she did not try two generic antipsychotic medications. She then said that we approved her husbands ******* and I let her know that I could not discuss that information since we do not have HIPPA permission to speak about her husbands medication. She was displeased and I let her know that she can get with her doctor to discuss next steps.

  We recommend you contact your prescriber and have them provide you with the list of medicine options you need to try in order to meet the Step Therapy requirements.

  My name is **** ****** and I am the ********************** of RxPreferred Benefits and if your challenge with this continues and you want to contact me for a discussion please do not hesitate to call my office at ************.

  If I can't answer or am away please leave a voicemail with your contact information and I will return your call.

  Customer Answer

  Date: 10/31/2024

   
  Better Business Bureau

  The resolution is NOT acceptable but I choose to no longer fight this since I will lose. For what its worth, the statement about not trying antipsychotics is also NOT correct  Antipsychotics are NOT prescribed for depression/ anxiety however SSRI, SNRI, tricyclics may be used.

  **** ******* RN, BSN, MA, MICN, TCRN

   

   

   

   

   

  
  
  Sincerely,
  
  **** *******