I spend much of my time fighting with insurance companies on behalf of other people. I'm pretty good at it. But nothing I know about fighting with insurance companies makes it any easier for me to fight the fight myself.
I have gastroparesis. My gastric emptying test shows 0% emptying after 90 minutes. What goes in just sits in my stomach for hours and hours. Without two medications -- Reglan and Protonix -- I either don't eat at all, or I vomit. A lot.
My insurance company, Anthem Blue Cross Blue Shield of Connecticut, doesn't want to pay for Protonix. For my $1000 per month premium, they want me to take Prilosec, Prevacid or Nexium instead. Anthem gets a better price on those meds. So once a year, they require that my doctor prove to them that I really, really need Protonix.
Last month, I filled my prescription. The label on the bottle said I had 2 refills left, so I didn't give it another thought. This week, I went to refill my prescription and it was denied. I need prior authorization for Protonix.
It's not like we didn't go through this a year ago. And it's not like anything has changed since then. But they make me jump through these hoops anyway.
I've tried all of the other meds. In fact, if Anthem would check its own records, it would see that it paid for them!!! If I proved to them a year ago that I've already tried those meds, then I've still already tried those meds this year. History doesn't change.
Next, Anthem wants to know why I need two Protonix a day rather than the usual one. A year ago or so, we tried to decrease the Protonix because it might also cause diarrhea, which is a problem due to my Crohn's disease. I immediately started vomiting. We told Anthem that a year ago. They want to hear it again.
Insurance companies won't let you have more than a 30 day supply of meds, so when it's time for a refill, it means I've just about run out of my meds. And I'm traveling this week-end, so not only am I going to run out, but I am going to run out far from home. Apparently, Anthem would rather that I end up in an emergency room hundreds of miles from home than give me enough medication to get me through the week-end, while they take their time processing a request for prior authorization that says NOTHING different than the one they approved a year ago.
Patients come to me expecting me to be able to fix this insanity. After all, I read all the time that one of the biggest problems with controlling the cost of chronic illness is that patients are non-compliant with medication regimens. I'm not non-compliant. I'm trying to take my meds; my insurance company apparently WANTS me to miss my meds for several days between the time I run out and they time they get around to reviewing my request for prior authorization. By then, I will be vomiting. By then, my illness will be out of control. I'm not non-compliant; my insurance company is.
And the worst of it is that I have absolutely no power here. None. I have good contacts at Anthem -- their lawyer, the head of their appeals unit. I have a friend at the Attorney General's Office who does health insurance work for consumers. I have all of the medical information and completely, totally understand what's going on here. And none of that does me a bit of good. Because I still don't have my medicine. I'm still going to get sick.
I know the rules, so I play by them. But why didn't Anthem tell me last month that I would need prior authorization this month so it could have been done in time? Why won't Anthem give me enough medication to get through the week-end when they know full well that I'm going to run out of meds and get sick? There is NOTHING I could have done differently, NOTHING my doctor could have done differently, that would have avoided this.
And nothing in health insurance reform is going to fix this sort of thing. Congress isn't even trying to address issues like this one. Indeed, our NIH study is showing that these sorts of coverage issues are the biggest problems people are having with insurance. Even when you have insurance, you pay your premiums, you do everything right, insurers can pull the rug out from under you whenever they like. And it's legal.
In the end, if I land in an emergency room because I'm vomiting a lot and can't keep anything in me, it costs Anthem more money than it would have cost them for my medicine. But saying that assumes the system is rational. And it's absolutely not. Jennifer
P.S. -- I GOT IT. It took relentless badgering of the insurance company, but they finally agreed to expedite the review and then they granted the authorization. It took about 2 hours yesterday and 2 hours today on the phone to make it happen. Had I not been going out of town, this definitely would have carried over to next week. Lesson: don't ever take no for an answer! J
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Hi Jennifer, since you posted on Protonix, I'll tell you what happened with me. I had to try Nexium and Prevacid for a few months each. I was finally approved for Protonix. It's cheaper than Nexium btw. I was approved for it but the pharmacy then had another week to wait because they couldn't get a price ;-). I finally received the generic version.
ReplyDeleteA few days later, I had to see the doctor for refills, etc. She had samples of something called Kapidex. She gave me 30 days of samples. It's time released for 24 hours and does stomach and intestines. The pharmacy held the prescription because they had never heard of it and neither had my insurance (her words). I'll wait until at least Thanksgiving before contacting them again regarding the Kapidex. I'm not sure if it works the same as Protonix but certain medications like Chantix sting at the full doseage--in my guts. I can't take it so I'm trying Kapidex to see if it helps with that.
Is it legal to overnight someone a weekend's worth of Protonix? ;-)
Rabbit
Jennifer, With my pharmacy insurer, CVS Caremark, I can request an emergency, expedited or 24 hour review. You have just enough time to do this now before the weekend. They have been good at that when a medication was absolutely necessary for me. I go through the same thing with Xolair as you go through with Protonix. Xolair costs $36,000 per year and it's the only thing we've found to improve my breathing when I was sinking below 47% of normal. So, year after year, the same medical issues come into play, but I still need to jump through the hoops. It doesn't help you, but I've marked a spot 2 months in advance and start on it then. Like you say, it is a terrible waste of time and expense. Please call them again and explain what is riding on the decision and that it's the same thing year after year. Most of all ask for an expedited review. I know I'm probably not saying anything you don't already know. It's just so maddening that the option is to be in the hospital or ER. An ER visit here is $3,000 to $5,000 too.
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