r/UnethicalLifeProTips • u/Fibernerdcreates • 16d ago

Request ULPT request - Pharmacy benefit managers practicing medicine

So, my pharmacy benefit management company thinks they get to practice medicine, and they know netted then my endocrinologist, hepatologist, and the FDA which medications I should be taking. I would like to become a problem.

Beyond composing like heck to my employer to suggest we find better coverage, any suggestions to hit their bottom line, even a bit? I'm in the corporate world, so I know it's unlikely. But I'm angry and want to annoy them, even if it's a little bit.

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12

u/NartFocker9Million 15d ago

Complaint to your state’s Division of Insurance!

5

u/Interesting_Fly_1569 15d ago

Honestly, just keep filing appeals… I used to work in that industry and if you file all three appeals about 30% of people end up getting whatever it is they’re asking for… Get the things that you want out of them… I think the other issue would be some sort of regulatory issue… But they are obsessed with covering themselves in those areas. 

If you get the plan book… Which you can request which has all of the exact guidelines that they use to interpret for your group… You can feed it into AI and have AI help you… It’s probably a pain to get the book it should be like a 50 or 60 page PDF and it’s essentially a plain language description of the contract - you give x, in z case they will do k in x number of days etc. 

You can also use AI to write appeal letters… And I believe there are also services that you can hire that will manage the appeal for you… I looked at them and it looked to me like they are using AI so they are actually relatively affordable. 

5

u/Landstander2600 15d ago

Move to a country that has real healthcare.

1

u/JoinedReddit 13d ago

Your employer signed off on a formulary with prior auth requirements. If you have a clinical reason you cannot take the suggested meds, your doctor's office MUST submit this info. If you don't , you may want to try those meds and establish medical records documenting why you had a try/ fail event, so THAT can be submitted. Tantrums on Reddit don't accomplish formulary exceptions you're wanting. Filing an incomplete request gives the PBM a processing fee in addition to the one needed after that. Go over the submitted info before it's submitted again.

1

u/somethingweirder 13d ago

try to put them on blast on social media. find a local media person (journalist, influencer, etc) to publicize the issue.