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Insurance Carrier: HMO Blue
State: Massachusetts

Consumer Complaint:

I have Lupus. I went to fill my Methotrexate today at two pharmacies. HMO Blue denied it saying it had to be a mail order. I was off of Methotrexate for a year but had to go back on. It has always been covered before. The problem is it is a $25 drug out of pocket. That is fine. I need it for tomorrow and I don't have time to wait for a mail order. HMO won't pay for the drug that is sitting in two pharmacies down the street but they will pay for me to go to the doctor every week to get the injection. So now they have to pay for the office visit, the medication, and for someone administer it. It doesn't make sense and it frustrates me. What can I do? I need this medication. I am sick and will be forever. The insurance company should be helping me and others. Any advice on how I can handle this?

Insurance Expert Answer:

Sure. The mail order drug company charges the plan far less than the local pharmacy. So the plan insists on mail order. However most plans allow a local participating pharmacy to fill the first prescription and use mail order for maintenance refills. Also, some mail order pharmacies have next day delivery. And the plan might conclude if you were off it for a year one more day is not life or death.