ComplaintsforHighmark Wholecare

• Initial Complaint

  04/02/2024

  Complaint Type:

  Service or Repair Issues

  Status:

  Answered

  More info

  I changed insurance on 4/1/2024 to Highmark Wholecare. On the evening of Monday, April 1st I attempted to pick up my prescriptions from Weis Pharmacy. Most of the items were already run through my old insurance prior to switching, however there was an issue with generic diclofenac gel. The pharmacist tried to re-run the prescription under Highmark Wholecare but it was also declined. On the morning of Tuesday, April 2nd I contacted Highmark Wholecare customer service to inquire what the issue was. I was told that too much of the medication was ordered, even though it was WELL under the quantity limit. The representative had me on the phone for 22 minutes only to tell me the situation was now resolved and the claim was paid. When I contacted the pharmacy, they informed me that the medication they had in stock for me wouldn't be covered because it wasn't a generic that Highmark would cover. I again contacted Highmark for clarification and was now told to either have my physician write an appeal for this generic drug that's on the Preferred Drug List OR call around to local pharmacies to see who had a generic in stock that would appease Highmark and CVS Caremark. That call was another 40 minutes with remarkably inept and uninformed customer service representatives. Highmark is denying care and has no way to assist a patient with a SIMPLE generic prescription that is WITHIN quantity limits and ON the Preferred Drug List.

  Business response

  04/12/2024

  This letter is in reference to the complaint from our member, Mr. ****** *. *******, ***. Per 
  the member, he was effective with Highmark Wholecare as of April 1, 2024. He states he went 
  to the pharmacy on April 1, 2024, to pick up his prescription for diclofenac gel and the plan 
  denied the medication. 

  
  The records confirm the member became effective with our Plan as of April 1, 2024. Please 
  know Highmark Wholecare covers certain brands of diclofenac gel. The pharmacy the member 
  went to did not have the brands we cover. 

  
  Please know our Plan covers the following brands:
  ? Arthritis pain reliever external gel 1%
  ? CVS diclofenac sodium external gel 1%
  ? Diclofenac sodium external gel 1%
  ? EG arthritis pain external gel 1%
  ? GNP arthritis pain external gel 1%
  ? GoodSense arthritis pain external gel 1%
  ? KLS diclofenac sodium external gel 1%
  ? QC diclofenac Sodium external gel 1%
  ? SM arthritis pain external gel 1%

  
  If the member needs help finding a pharmacy that has these specific brands, please have him call 
  our Member Services Department at ###-###-####, they will be happy to help.

  
  Per the member he states on April 2, 2024, he called the Plan and was told too much of the 
  medication was ordered even though it was well under the quantity limit. The member stated the 
  Plan had him on the phone for 22 minutes only to tell him the situation was now resolved, and 
  claim was paid. 

  
  After review of the member’s call, the records show he called on April 2, 2024, regarding his 
  prescription. The customer service representative (CSR) tried to assist him and contacted our 
  Pharmacy Department and the drug store. The records show he was on the phone for about 22 
  minutes. The CSR did inform him the prescription was out of stock and on back order with the 
  drug store. Once the member heard that, he ended the call. 

  
  The member states he called the pharmacy and was told they do not have the generic in stock. 
  This is correct the brands Highmark Wholecare covers is out of stock, which may be a possible 
  supply chain issue per the drug store. Please note as stated above, we cover other brands. 

  
  Within the member’s grievance he states he called the Plan again and was told to have the doctor 
  file an appeal or call other pharmacies to see who had the generic brand. He states that was 
  another 40 minutes. He also stated the CSR was uninformed.

  
  That call was also reviewed, the records do not show the call was 40 minutes. The member was 
  informed appropriately of his options: find another drug store that carries the brand we cover, 
  offered to file a grievance, which could have assisted him finding the brand that we cover. The 
  member was also offered to have his doctor call in and request the non-formulary brand. 
  Please know the CSR did inform the member appropriately. 

  
  Lastly, the member states Highmark Wholecare is denying care and has no way to assist him 
  with the prescription, which is within the quantity limits and on the formulary. 

  
  Highmark Wholecare is not denying the member’s care. As stated above, there are specific 
  brands we cover, and the one is currently out of stock at the drug store he went to. Please know 
  we have no control of out-of-stock items. We spoke with the drug store, and they are not sure if 
  they can get that one in again, due to a possible supply chain issue. The drug store is working on 
  it. 

  
  The medication is on our formulary, and it does have quantity limits. The issue was the drug 
  store was out of stock of the brand we cover. 

  
  The member will need to find a drug store that carries the brand we cover. We have referred the 
  member to our Care Management team to assist him with his concerns. If they do not call within 
  the next week, please have the member call our Member Services Department and he can be 
  transferred right to the team. 

  
  If you have any further questions, please call me at ###-###-####.

  
  Sincerely,
  Toni Marie B*********
  Sr. Quality Analyst
  Highmark Wholecare
  
  

• Initial Complaint

  02/27/2023

  Complaint Type:

  Delivery Issues

  Status:

  Answered

  More info

  This company is currently running sponsored ads telling the public that id they meet certain requirements, they will be eligible to receive a food and utility card with a pre-determined amount. I was accepted and expected to receive my card. However, this never happened. I never received my card. I NEVER RECEIVED A REPLACEMENT CARD EITHER. Instead, I was told to keep waiting and call back another day.

  Business response

  05/10/2023

  UPMC Community Health Choices, Inc. (“UPMC CHC") is in receipt of your letter dated January 12, 2023 and accompanying message from ******* *******. As we believe this situation now to be resolved, we can offer the following response. 

  
  UPMC CHC received the first complaint from Mr. ******* regarding this issue on October 7, 2022. This complaint was conveyed over the phone to a UPMC CHC Member Services Representative. An acknowledgement was sent to Mr. ******* dated October 10, 2022. On October 15, 2022, UPMC CHC Complaints & Grievances received a fax from the member.1 This contained, among other things, a copy of an invoice from a company named People's Electric dated October 12, 2022, which Mr. ******* indicated was for the repair of his broken lights due to the home modification by Liberty Wheels. This invoice listed $260.00 as the amount owed. On the bottom, next to Mr. *******'s signature, was written "$260.00 paid cash." 

  
  UPMC CHC has reimbursed Mr. ******* for $260, the amount listed on the invoice that was submitted to us on October 15, 2022. This amount serves as reimbursement in resolution of this issue. The check was dated March 2, 2023, and we have received confirmation that Mr. ******* received and cashed it. Additionally, UPMC CHC will continue to ensure that all work tasks related to benefits provided under the plan are performed professionally and completed per written work orders. As such, we believe this matter to now be closed. 

  
  Should you have any further questions, please contact me at ###-###-####. 

  
  Respectfully Submitted, 
  

  
  Steven A. V****, Esq. Staff Attomey UPMC Health Plan 
  

  
  

  Business response

  05/16/2023

  This letter is in reference to the complaint ***** ******* filed. Per Mr. *******'s complaint, he states Highmark Wholecare is running ads telling the public if people meet certain requirements, they are eligible to receive a food and utility card with a pre-determined amount. 

  
  Please know, our Diamond plan does offer healthy food and utility support benefit. These benefits allow $135 per month for the healthy food t and $100 per quarter to be used for plan approved utility expenses. The food benefit expires at the end of the month and the utility benefit expires at the end of the quarter. The benefits are outlined in the 2023 Evidence of Coverage booklet, which can be found on our website, *****************.com. 

  
  In addition, for someone to be eligible for our Diamond plan, they need to have both Medicare and Medicaid coverage. A member's eligibility is only used for which plan the member can enroll in. The healthy food benefit and the utility support benefit are the same for all Diamond members. 

  
  We are unable to determine what advertisements Mr. ******* is talking about. There are flyers that went out for potential members, which explained the healthy food and utility support benefits in detail. This flyer only stated what the Diamond plan offers. 

  
  We do offer two different plans, Diamond and Ruby, for people who have both Medicare and Medicaid. The Diamond plan is the plan that has the healthy food benefit and utility support benefit. The plan you are eligible for is based on your Medicaid coverage. Mr. ******* called our Plan to enroll and during that call the benefits were explained in detail to include the health food benefit and the utility support benefit. 
  Health benefits or health benefit administration may be provided by or through Highmark Wholecare, coverage by Gateway Health Plan, an independent licensee of the Blue Cross Blue Shield Association (“Highmark Wholecare"). Highmark Wholecare offers HMO plans with a Medicare Contract. Enrollment in these plans depends on contract renewal. 

  
  Mr. ******* states he was accepted and expected to receive his card, but he did not. Mr. ******* states he never received a replacement card. 

  
  The records show Mr. ******* enrolled in the Diamond plan effective February 1, 2023. His first card for the benefit was mailed to him on February 2, 2023, to the address on file. A replacement card was sent to the address on file on February 15, 2023. 

  
  The records show Mr. ******* used his March and April food benefit and used both his first and second quarter utility support benefit. Mr. ******* did not use his February food benefit. As a one-time courtesy, we have refunded Mr. *******s's February benefit of $135 to his card. Please know the February benefit will expire on June 2, 2023. 

  
  Lastly, Mr. ******* mentions when he called about the benefits, he was told to wait and call back another day. As stated above, Mr. *******'s first card was sent February 2, 2023. Mr. ******* called February 10, 2023, about the card. The agent did tell Mr. ******* since his card was sent February 2, 2023, to allow at least 7 business days for the card to arrive. 

  
  Mr. ******* called back on February 15, 2023, and a new card was ordered and sent out. Please know, the February 15, 2023, call was ended by Mr. ******* prior to the representative assisting and educating Mr. ******* on other ways he could use his benefit while waiting for the card. 

  
  As stated above, Mr. ******* used his entire March and April food benefit and his first quarter utility benefit. 

  
  We apologize for Mr. *******'s experience. 

  
  If you have any further questions, please call me at ###-###-####. 

  
  Sincerely, 
  Toni Marie B********* Sr. Quality Analyst Highmark Wholecare 
  

  
  

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