Every once in a while, filling a new prescription goes beautifully. The doctor calls the pharmacy, the insurer picks up the tab, and I walk away with new medication.
Oh, you’ve had that fantasy too? My recent experiences have been quite the opposite.
My new weight-loss dream-team doctor prescribed me the latest diabetic wonder drug, Byetta (which, as I read in the New York Times, is made, essentially, from lizard spit, but more on that later). Byetta is easy to get—if you are rich. For me, the insurance provider wanted to put up a fight.
My doctor called in a prescription on Jan. 17 for a 5 mcg pen, with measured doses for 30 days. But when my wife arrived at our local drugstore, the pharmacist told her that we didn’t have proper authorization for the medication to be covered by insurance.
“Isn’t that what a prescription is?” she asked. “How much is it out-of-pocket?”
“$246.”
I called our insurer, who assured me the mistake would be cleared up in a few days. I went back to the pharmacy three days later—still no luck.
I had now officially entered into the free market prescription drug quagmire. So I did what any person faced with navigating a truly befuddling bureaucratic muddle would do. I raised the volume.
“Please calm down, sir,” said an insurance rep at the other end of the telephone line. “How may I help you?”
“You can fill my prescription.”
“Are you referring to your Byetta? You need prior approval. Please lower your voice.”
“I have a prescription.”
“Yes, but you need a letter of medical necessity from your doctor. We faxed one to him last week.”
I emailed my doctor, who was chagrined to find out I had not started taking my drug. “We need to get you started,” he wrote back. “They haven’t requested anything from me.”
(Insert screams of exasperation here!)
I began to consider this issue from another perspective. I wasn’t going to die without Byetta, but what if I had clots and this was a blood thinner? What if this drug was to treat heart failure, or to smooth a difficult pregnancy? Why is it so hard to get a straight answer from my insurer or my pharmacist?
By day 15, I’d had it. After much shouting on my end, a woman from the insurance company calmly explained that high-priced brand-name drugs like Byetta required a form from my doctor—and that the prescription be filled through the insurer’s mail-order pharmacy, causing yet another delay in the process.
I asked her what I could possibly have done to avoid this problem.
“We usually recommend you get prior approval.”
Thanks.
Comments (4)
Maybe it was the way the doctor prescribed it…if they prescribed it for weight loss and not diabetes i can see the insurance company giving you a ahrd time
this could’ve been written by me. this is exactly what happened to me to the letter! i am on my 3rd level appeal from my insurance company. i have one more, which is an arbitration like appeal to someone on the outside of the insurance people. they say my diabetes isn’t bad enough! i am a nurse and need to live! i’ve taught people about diabetes for 30 years. do they think i’m actually going to let this get bad before they give it to me? they got a letter from my doctor twice, they won’t even talk to him or let him speak to an endocrinologist. do you have any suggestions?
We, as the “employer” of the Ins. co.’s, we pay their salary out of our healthcare deductions each paycheck, must band together and demand the so called ‘Benefits’ we work so hard and pay so much for through our jobs. We are allowing the Ins. Robber Barons to price gouge and then they refuse to pay the prices they set! They get away w changing rules as they go and denying critical meds. NO MORE! WE must fight. Only 15% of denials are appealed. Share info, keep fighting & help each other.
My most recent exp. with a Major Prescription Insurance Company (available on request) is that they keep upping the requirements on the patient end to qualify for meds that have been approved year after year, through the agonizing and painstaking “prior authorization” process. Once the alternative meds have been exhausted, this is no longer enough, (though they state that it is enough in their own letters); now, they say the alt. meds have to FAIL! Meaning it is not enough that no other meds will work, suffice or even come close to achieving desired effects, NOW the list of alt. meds have to cause an absolute ADVERSE REACTION!!! As if being inefective is not an adverse reaction in and of itself. After providing all of this and managing to keep my Dr.’s office staff still engaged, (God Bless Them All for their endurance), I’m sure the Insurance will up the ante and make up a newer and more impossible set of criteria before denying the meds that they have for years approved. Many patients could lose their lives in the time this takes. Any advice? Other than being a billionaire and surgically cutting out the Insurance companies altogether??? Be certain that the “some people” are getting theirs and plenty more.