Thursday, April 24, 2014

The Game of Numbers

This week has been a bit stressful.  We went to refill a prescription for my son only to find out the insurance had denied coverage for it and wanted more information from the prescribing doctor.  After further digging, MANY phone calls, and emails, we found out that our "wonderful" insurance has decided that my son's condition warrants a "step" program for medication, that we did not know about until now I might add.

What's a "step" program?  It means that the powers that be have decided that they only want to spend as little money as possible so that require you to try a medication that has a generic first.  If that doesn't work, then you can move up to a Step Two medication, which is a little more expensive but doesn't make their tightwad accounting books scream in agony.  If that medication is deemed as not working, then you will be blessed by the insurance gods to be allowed to be prescribed a Step Three medication, which is what my son is taking.

Here's the kicker:  The paid for the initial filling of this medication but "only as a courtesy" they wrote in their letter.  And then waited until we tried to refill it to deny it and start the prior authorization process, which meant that either my son went without meds, we started over with a new medication, or we paid for it ourselves at the tune of $222.98 per month.  Now remember this little guy is only 4 and we have been trying for over 6 months to find a medication that would work for him and FINALLY found one that not only helps him but that he willingly takes and says that it helps him.  Plus it is a liquid, which helps in my little guy in taking it.

So now here we are sitting and waiting for somebody who is not a doctor and who has never seen or met my son make a decision as to what type of medication "is best" or in other words what type of medication will cost them the least and forget what works or what is best practice for this child.  Never mind the fact that they are suggesting making a guinea pig out of my son and force his body to go through changes on medications and all that goes with that.  Have I mentioned I HATE our insurance company?

Oh, yeah, and they would not send the paperwork to the prescribing doctor (who refused to call the insurance company to request the paperwork) to fill out for them to "make their decision" until my husband sent a not nice email to his HR department telling them how bad the insurance company sucks and how uncustomer friendly they are.  And my husband did that after I called him in tears because when I called the insurance company to ask them to send the paperwork was told that I was not allowed to do so even though it is my son that is affected.  They said only the prescribing doctor could request the paperwork be sent, which the doctor refused to do stating he did not have the staff or the time to "sit on the phone for 15 minutes" to talk to someone with no medical degree to justify his reasoning for prescribing the medication he did.  Consequently, we are stuck between these two entities over a power struggle regarding money and power.  Yeah, it has sucked. 

But the paperwork has been sent to the insurance company by the prescribing doctor, and the insurance company made it VERY clear that they have four business days to make their decision.  Awesome!  Way to do what's best for the patient!  NOT!  (I won't say who the insurance company is, but I can guarantee you have seen their commercials and how they are there for you as the customer no matter what the situation in your life and always will be.  What a laugh!)  In the meantime, we paid for filling this month's prescription completely out of pocket because everyone who IS involved in my son's life and HAS SEEN him or worked with him has noticed a dramatic improvement in his behavior and thinking and we didn't want to hamper that progress due to a bureaucratic/power struggle showdown.

So here we sit and wait, and wait, and  . . . . . . . . .

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