prescription provider smarter than doc - again

being oh so much smarter than my pdoc and her experience, especially in treating me, they have declared the med that has done me the most good is prescribed with a dosage they do not recommend and will not cover....like we have spent YEARS arriving at this particular regimen and now they want to jack with ... they have pulled similar boneheaded moves in the past

they don't seem to know this can be dangerous, I sent email one time asking if they were really going to take the anti-psychotics coverage away from us crazy people...I guess I wasn't the only one because they changed their minds

so even though I've persevered to even have the insurance and pay the monthly premium, which will surely be increasing next year, I have to go out and pay out of my pocket to get what I need and I don't know how long I'll be able to do that having been BULLIED out of my job and therefore no income...Medicare will be kicking in soon and I wonder if part D is going to be better than this crap

sorry for the rant, something will work out but since I'm still working on eligible posts I thought I might as well

stephanie

It just amazes me about all the insurance stories I hear on this website (and others). It seem the main point of insurance companies is how to best screw the clients.

I can't begin to understand how you feel since I am on disability in Canada so everything, including glasses and dental care is covered.

I know here in TX Medicaid is harder to get but it worth it to see if you can qualify. They have several types, qualified medical benefits(QMB) low income medical benefits, qualified disability and working individuals medical benefit(QDWI) and maybe others. My QMB covers the extra costs and covers the donut hole cost, since my AP is expensive I wouldn't be able to afford it without this extra help.

Dftsteph, my h and I have had similar difficulties with our insurance, including with a cancer med for my h.

This is what worked for us: I called and talked to the doc's medical assistant. If your pdoc doesn't have one, you can talk to whoever answers the phone, except the answering service.

Tell them what's going on, without ranting. The provider is trying to change the doc's prescription. The doc can fill out some forms that explain the need for the drug and the dosage.

Doctors are used to doing this. In my case, the situation was settled in my favor in less than one day. In my h's case, it took a week, and I also wrote an appeal. His medicine costs $1400 a dose (saved his life.)

After they'd hassled with me on three meds, I was able to call them on the fourth one and they approved it over the phone and even apologized.

You can also find out what the appeal process is and appeal it to the provider yourself. Again, don't rant. The best approach is to say that without this drug at this dose the risk of relapse and expensive hospitalization is very high.

Even if you've never been in the hospital, you can honestly say that you've been taking the med at the doctor's prescribed dose and it's relieved symptoms and made you more functional. If the regimen is changed, the risk of hospitalization is high and that would cost a great deal more than the medication.

Unfortunately, cost is what the insurance company cares about. If you can effectively argue it's cheaper to keep you on the medication, you have a chance of winning your appeal.

But first call your doctor's office and tell them what's happening and ask them if they can intervene with the insurance company. Most doc's will.

If you have an insurance handbook, look up the appeal process. If you decide to appeal the decision yourself, make sure you follow the process as outlined in the handbook to the letter.

The approvals are usually good for a year so you might have to do the same thing again a year later.

The first time they denied me I was totally freaked out and didn't know what to do. After reading the handbook and talking to the doc's staff, each denial is just an annoyance now. So far, nothing's been turned down for good. We just have to justify these really expensive drugs.

We just received notice that my h's medication has been approved for another year. The doc's receptionist filled out the form and it was okayed within a week. But my h had to go in and personally ask her to fill it out because it had been sitting on her desk for a while. That's worth about 18 grand. And his life. So we're willing to jump through any hoop they put in front of us.

I hope your doc will straighten this out for you.

I am brand new to Medicare and trying to learn all the ins and outs of it . . . which is pretty complex in my opinion. Sidestepper mentions some programs that I am learning about. Here is a link that I think is very useful for anyone new to Medicare: Seniors & Medicare and Medicaid Enrollees | Medicaid.gov

This website, at link above, explains "dual eligibility" for persons who can get both Medicare and Medicaid.

thanks for the responses...I'm feeling a little calmer

I'll see what I can do with the insurance company...I know I can't go off on them because supposedly they can withdraw this retiree "benefit" at any time

doc sounded like she had talked with them....she's not real coorperative about paperwork...she mumbled something about adjusting meds as we get older, but they're cutting me from 625mg to 300mg and she wrote me a separate script for another 150mg to get out of pocket

I'll also check into the Medicare/Medicaid thing...I really appreciate the
cool-headed options you all have come up with...when I get into that freaked out zone, I can't even see anything else except that it makes no sense

...stephanie