Health insurance bullshit

[shadesong]

I'll bold the parts that I find to be especially made of FAIL on the part of the system.

* Was unable to reach rheumatologist yesterday in time for them to call in my Celebrex prescription.
* Called this morning, had them call it in.
* Called pharmacy to make sure everything was in order before Adam trekked over there.
* Pharmacy said they couldn't fill the prescription, because it required prior authorization. They said they notified the doctor. (They did not notify us.) We told them we had a prior authorization form on file. They claimed ignorance.
* Called the doctor. Doctor's office said the pharmacy did not notify them. They were unable to grab my file, as the doctor was in his office with a patient, but they said prior authorization generally lasts a year. It has not been a year.
* Called the insurance company. They said it was a six-month prior authorization, and claimed that they sent a letter telling me when it would run out. They did not. (I save every bit of medical info. My file cabinets are impressive.) They said to have the doctor's office fax over the paperwork.
* Called doctor's office, they're faxing, we wait.

Now, I've gone into my issues with Prior Authorization before. Simply stated, if my doctor prescribes something, I regard it as being fucking well authorized. I don't think the insurance company has any place here. I had to fight them regarding anti-seizure meds, I had to fight them for Lunesta (twice), and I had to fight them for the Celebrex (less than six months ago, I bet). What is this prior authorization bullshit? I ask you. No, seriously, I ask you. If anyone knows, please tell me. Because I'd like to know what the thought process (or lack thereof) is here.

The extra problem here is this: We'll be at Boskone all weekend, and we're flying to Arizona on Monday.

My last Celebrex will be tomorrow morning.

So if this doesn't get dealt with today, I am so screwed. I can deal with a day at a con sans Celebrex. But four, five hours in a plane will be brutal anyway. Without my anti-inflammatory? Oh hells no.

*breathes*

Yeah. You want to know why I don't get more writing done? Because I have to spend all my time dealing with this bullshit. When I'm not incapacitated by the medical issues that are the impetus for this bullshit. And, y'know, sometimes there's overlap, and isn't that great fun.

Comments

[liamstliam.livejournal.com]

Is the pharmacy open Sunday?

[shadesong.livejournal.com]

Yeah. We can pick it up on the way back, if it's filled.

But the insurance company doesn't work on the weekend. So if it's not reviewed today? Screwed. So we have to hope that the doctor's office has already faxed it over and that the insurance company person has run the form over to the people who need to review it herself and in person and has told them it's an emergency.

[liamstliam.livejournal.com]

Yes, I know they don't work weekends, but I was thinking that if it was filled after you leave for Boskone, we could get it Sunday if they filled it.

[feste-sylvain.livejournal.com]

This happens to you far too frequently.

There is incompetence in the system which is going unpunished; there is even some incompetency in the system (specifically in the insurance company) which is being rewarded.

I note that the one piece of the system (your doctor) which is working properly is the one piece which you were able to choose. The rest appear to be coasting on insulation from your wrath.

[robyn-ma.livejournal.com]

Point at who you want us to beat up. We will beat up them.

[norda.livejournal.com]

I hear you in stereo. I'm going through the process of applying for fuel assistance and food stamps for the FOURTH time, because they keep asking for the same DAMN PIECES of paper I've given them FOUR FUCKING TIMES.

This red tape is keeping me from doing the sales work for marketing BLAKE'S 7, THE SCARIFYERS, and the other book and audio titles we're trying to distribute, sales of which if they got off the ground would mean I WOULDN'T NEED FUCKING FUEL ASSISTANCE.

Sorry for "yelling". But I do hear you on this. In stereo.

[harkalark.livejournal.com]

Cinammon Toast Christ. What is wrong with people.

[dracosphynx.livejournal.com]

Just out of curiousity, have you asked the pharmacy what the price of the medication is without the insurance? More specifically, have you asked what the bulk rate is?

I only mention this because I learned something really strange about it when dealing with my thyroid medication -- it's a daily pill I will probably be on for the rest of my life. However, the insurance companies will only authorize a 30 day dosage at a time. At one point, with my co-pay, I was paying about $10 per month. *However*, if I skipped the insurance companies directly and got the perscription in bulk of 90-100 pills at a time, it cost me $18 for the bulk purchase without insurance, as opposed to $10 for a 30 day supply with.

So, it was actually *more expensive* with the insurance company for a three month supply! I have no idea if this applies to your situation or not, though. (Also, there may be shelf-life issues.)

However, you may need to have the doctor write a bulk-sized prescription -- you might have to first ask the pharmacist for optimal non-insurance pricing/quantity, then take that to the doctor for a prescription which says "VAST QUANTITIES!", then take it back to the pharmacist. However, it may actually be cheaper (in some cases) and completely cuts the insurance company out of the loop.

The only annoyance I have is that the phamarcy tends to try to automatically set up refills for monthly amounts because they assume I will be using insurance.

[microwench.livejournal.com]

Hmmm...This is interesting. I bet this is only good for meds other than psych or pain meds. I doubt I could get my Fluoxetine or Ultram that way. But...I wonder...maybe this could work for my Momma.

[dracosphynx.livejournal.com]

Dunno. It just seems very strange. Bizarrely, I learned about this while doing jury duty in a personal injury case. The lawyer was laying out the medication costs that were being asked for, and indicated that these were specifically bulk rate costs, not 'prescription' costs, and therefore cheaper. That kind of puzzled me, so I asked my pharmacist, who called up the numbers on my pills and told me, yes, it was cheaper for me to go without insurance if I could get a bulk prescription.

Essentially, my pills come into the pharmacy in a big bottle of 100. For a normal (with insurance) 30 day supply, the pharmacist just counts 30 pills out of that bottle, puts them in another bottle, puts the prescription label on it, and involves the insurance company, which results in me paying about $10 per 30 pills, or about $0.33 per pill.

However, if my doctor wrote a prescription for 100 pills at a time and when I gave it to the pharmacist I specifically said no insurance (if I didn't, they assumed insurance and changed the doctor's prescription to 30), then they would go, get an unopened factory bottle of 100, slap my prescription labels on it, and sell it to me for $18, or $0.18 per pill.

It does take a little research (you need to find out what the 'bulk' container/price is, and if the shelf life works out. If the shelf life of the medication is 6 months, buying a year's supply at a time isn't going to work), and get the doctor to write a prescription for that much at once, and make sure the pharamcy understands this is without insurance, bulk rate pricing, don't screw with the quantity.

I've generally found the phamarcy doesn't give that much active hassle about it, but that they do need to be watched because they will, by default, automatically switch back to insurance rates/quantities every time if they aren't reminded. And once they modify the prescription to do a 30 day supply, you have to go back to the doctor and get the bulk rate quantity authorized, again. Of course, with a multi-month supply, I don't have to go to the pharmacy as much, so.

[wednesday]

Fluoxetine's been around for ages and is shiny generic; you might well have a chance with that.

[jenphalian.livejournal.com]

My mom gets ultram this way.

[jennifer.livejournal.com]

As someone who used to work in the prior auth department of an insurance company?

It's fucking bullshit, designed to make it so that the patient either gives up or asks to get put on a generic, which is cheaper. Either way, it's about money in the fuckin' insurance company's hands and not about patient care in the slightest.

I am sending feel-better vibes to you, and a cluestick to the insurance company.

[kythryne.livejournal.com]

I suspected as much. My insurance company has been an ass about letting me have Lyrica, supposedly because they want to make sure I really still have fibromyalgia. Hey, that part where there's no cure? And the bit in my records where it says that I was first diagnosed over a decade ago? Yeah.

Sorry you're going through this, 'song. It blows.

[shadesong.livejournal.com]

They gave me shit about Lyrica, too. Lots and lots of shit. Seven months' worth.

I hope yours gets straightened out soon...

[kythryne.livejournal.com]

Oh, sheesh. That's just ridiculous.

They did eventually decide that oh, hey, I do have fibro!, but it may be a moot point in the end, as it looks like I'm possibly allergic to Lyrica. Either that or Ambien.

[shadesong.livejournal.com]

Eek!

[kythryne.livejournal.com]

Yeah. Nothing life-threatening, mind you, but constantly wanting to claw my skin off is not my idea of an acceptable side effect. It got to the point where I was looking FORWARD to having to wrestle the dog through her thrice-weekly baths, because when I slather her with cortisone goo afterwards, I also end up covered in the stuff. *wry grin*

[shadesong.livejournal.com]

See, that's pretty much what I figured.

Problem here is that much of what I'm on, there's no generic for. And in some case, I cannot take anything other than what's prescribed. The anti-seizure meds, for example - they all work in different ways, so Drug A, while cheaper for the insurance co, simply Does Not Work on my seizures and/or gives me unlivable side effects, so I have to have Drug B, no substitutions. I should not have to argue with them about that, y'know?

[jennifer.livejournal.com]

No, you shouldn't, and especially not for something as important as your anti-seizure drugs. No way, no how.

That attitude - the "hur hur hur, we're not doctors, but we know best" thing - is a large part of why I said goodbye to that job. I couldn't deal with the crap anymore, and I couldn't deal with the people yelling over the phone; I understood where they were coming from and I empathized completely, but my hands were tied. I couldn't take it.

[ringrrl416.livejournal.com]

The deal with prior authorization...i think... is that it is not a medication your insurance covers for what ever the meds is typically used for.

IE they have something else that they prefer you to be on b/c its cheaper for them (when we all know the way a medication affects each individual person is different)

But if your doctor sends the insurance certain paper work, saying "'song has to be on THIS medication" the insurance company has to cover at least some of it.

So basically the insurance doesn't cover Drug A normally, but because your doctor tells them Drug A is the only thing that works for you, they kind of have to cover it.

problem is: paper work gets Fucked up all the time, techs don't necessarily look at the notes on your file when the fill a script (especially if its busy in the pharmacy at the time) etc

(I use to work in a pharmacy. ) The other thing is, a lot of the time, its not the pharmacy that fucks up, its the insurance company. So pharmacy might have input the PA number 20 times, and insurance company tells them its incorrect

But i agree, the pharmacy should have called you. Ask them to put something on your file that says call whenever meds are ready/anything is wrong.

[ellyssian.livejournal.com]

I had the insurance company go through a fit like this on the third refill out of three on a med I'd been taking for a while, but, unfortunately, failed to fill in advance before switching to Jerkass Insurance Company (aka Aetna).

They wanted a phone call from the doctor saying I needed to take the crap.

I decided not to take it - or refill anything else - for nearly a year. The blood pressure kind of got out of hand again, though, so I 1) found a doctor I liked (that part of the equation was in failure-distrust mode anyway) and 2) tried a few different things until I found stuff that worked, and haven't run into any trouble from the insurance company since.

[ysabetwordsmith.livejournal.com]

You've just demonstrated why. Insurance companies are all about making money, not helping people. They can't *outright* refuse ever to pay for health care. So what they do is make the process a nightmare, which has two effects: 1) it makes the process so difficult that much health care gets blocked, reducing costs, and 2) it generates so much stress that some patients drop their policies, commit suicide, or die of complications, also reducing costs. It's evil -- but it's not illogical if you follow the money.

[dracosphynx.livejournal.com]

Actually... have you asked how much the medication is *without* insurance?

I've no idea if your copay or costs with insurance are 10% of the medication costs, so insurance is good, or if they are 90% of the costs, in which case it could be skippable if you needed it before the con. (I only ask because I've had prescriptions that were, essentially, $10.50, where I had a $10 copay, meaning the insurance company only covered $0.50 of the costs. Pfft.)

[mycroftca.livejournal.com]

Don't forget, insurance companies are in the business of not serving you. They ignore doctors consistently. They have their own doctors on staff working to keep you from getting what you and your doctor think you need, practicing medicine by phone, rather than by examining patients.

They aren't your friends.

Celebrex

[chrystie69.livejournal.com]

If you don't get your Celebrex Email me - Chrystie at gmail dot com if you don't get it by Sunday! Are you going to meet us at Publick house Sunday? If you don't get it I can give you enough to get you through! My script is for 2 a day but normally I only take 1 so have extra!

Re: Celebrex

[alethea-eastrid.livejournal.com]

Not sure if 'song's going to be there, but we will be able to act as courier if needed...

[vash137.livejournal.com]

Fucking health insurance system!!! I hope this all get sorted out. Sounds like a nightmare.

Hugs :)

[juushika.livejournal.com]

I know when I went on Wellbutrin for depression, I had to go through the same hoop-jumping of prior authorization. In that case, it was explicit contact between my prescribing doctor and my insurance company to verify that the medication would be used to treat depression (which the insurance company covers) and not to treat a smoking addiciton (Wellbutrin helps control impulse cravings, but the insurance company did not cover this [expensive] medication for help quitting cigarettes).

Which is a very different situation, no doubt, but I will agree to this:

The insurance companies limit what they cover, how they cover it, what uses of a medicine they cover, who they cover ... as much as possible. They make the outlook seem broad, but add is as many fine lines and distinctions and exceptions so that they can deny treatment whenever possible.

You may have better luck with getting the doctor/insurance/pharmacy contact all sorted out if you or Adam go to the pharmacy and stand there. Calling ahead gives them plenty of time to try to make contact and fail; standing there in line puts a greater sense of urgency on the matter. It can be a pretty painful wait, trapped at a supermarket, but I had good luck just going there and standing there, so they could see me, so they kept trying to make sure everyone got in touch with everyone else.

[rowancat.livejournal.com]

Sympathies. I've been through a variation of this song and dance, running back and forth between a clinic and a pharmacy, wasting a whole afternoon once.

[cissa.livejournal.com]

Insurance companies make their profits by denying care. This is obvious, and why private insurance is a Really Bad Idea.

[redknight.livejournal.com]

I hate to be so cynical, but as someone with more medical issues than I like to think about, I've come to think you're right.

The insurance company doesn't care that they're making things difficult, in fact the seem to like it and will be happier if you get frustrated and go away (so they don't have to spend money on your care).

[jenphalian.livejournal.com]

Pre-auth is bullshit. My doctor wanted me to have an MRI to see what the hell was growing to fist-size under my uterus, but they couldn't schedule me for it without prior authorization. Since the pain wasn't really bearable anymore, I ended up in the emergency room, then having surgery instead. Two days AFTER the surgery, the insurance company called lbitw's office to tell them I could have an MRI.

Gee, thanks, glad I didn't wait around to die.