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        New Message Board Archives >> 2004 Cluster Headache Specific Posts >> Re: %&*!@ Insurance Companies!!!!
        
(Message started by: thomas on Feb 4^th, 2004, 11:14am)

Title: Re: %&*!@ Insurance Companies!!!!
Post by thomas on Feb 4^th, 2004, 11:14am

Stay after them, they will give in soon. Your pharmacyst can check on what meds your insurance company will authorize.

Title: Re: %&*!@ Insurance Companies!!!!
Post by don on Feb 4^th, 2004, 12:23pm

Just have the doc write a letter of medical neccesity.

Title: Re: %&*!@ Insurance Companies!!!!
Post by cootie on Feb 4^th, 2004, 12:28pm

Insurence co's make a liveing tryin to figure out what you need the most so they can cover it the least. We've had our share of crap with them. Our new policey thru the same co we had does NOT pay for scripts now starting Jan 1st till we meet a big ass deductable for EACH of us. I jus got a bill from the hospital for exrays I had done back the 1st of August.......paid $ 500.00 for all of them cuz they won't pay till I meet my deductable of course which is $ 500.00 but now it starts over. OK....so did they purposely HOLD this last bill so it would run over to the year 2004 ? (since I would of met my deductble and it that last bill been mostly paid) Of course the bill is late cuz I NEVER GOT IT ! (that makes 6 bills total for two sets of exrays that took a few minutes) Got scripts ta pick up today and PAY the full amount on still...not reached that deductable yet and I have paid in alot this year on em so far. Fuckers and Theives pardon my french Pam

Sorry....ya got me started.......oops !

Title: Re: %&*!@ Insurance Companies!!!!
Post by TxBasslady on Feb 4^th, 2004, 12:28pm

This seems to be an ongoing problem for alot of folks. Makes sense to me that if the Insurance co's fill the rx one time.....and if the rx is for multiple refills.....then what the hell is the problem. They will say it's cost of the triptans. I think this is bullshit!!

My husband takes Zocor for his cholesterol. The Zocor costs MORE than my triptan drug. But there is NEVER a problem getting the Zocor filled.

When my doc gave me the rx for Frova....the insurance co approved the rx. I paid our standard co-payment. Second refill????........well I had to pay $60.00. Third refill????........I had to pay $86.00. Was advised by the pharmacy that IF I get it refilled again.....I have to pay full price!

I think that if the insurance companies and the doc's were well versed about CH, then all this would not be a problem. Sheesh...........the drugs to half-ass help with the CH are out there.......we have CH.........give us the gawd damned drugs.

Of course, alot of this is one of the goals for OUCH. This is why our membership in OUCH is so important.
I know that Cat and Tracey made some accomplishments on the trip to NE. Without this interaction between drug manufacturers, docs, and patients, we are gonna always have this problem.

IMO.......I don't see how in the world anyone without insurance can afford these meds. They're damned expensive WITH insurance.

Well, now that I'm all riled up..............think I'll find the ph number for my Congressman.LMAO I'm certain that he/she is interested!!! ::)

PF vibes,

Jean

Title: Re: %&*!@ Insurance Companies!!!!
Post by peteyg on Feb 4^th, 2004, 1:38pm

I think Zocor is fully covered because Ins. Co's would pay more for high cholesterol-related problems if they didn't fund it. >:(

Triptans are pain relief. And for headaches. Who ever heard of someone dying from a headache? That would be their way of thinking. :-X

The long term benefit would not justify the cost. Remember, they are not thinking of the patient, just the short and long term financial benefits of providing care. If paying for triptans now does not result in saved costs later, then there is no reason for them to do it. >:(

That said, I just paid $185 last week for 9 (nine!) imitrix tablets, because my insurance would not pay for them, and my headaches were unbearable without them. I finally got switched back to my old Dr. (who's 80 miles away from my house, but so worth it), who immediatly called in my Prednisone and Verapamil to my local pharmacy, just from talking to my wife on the phone.

For anyone in the San Diego area, Dr. Stuart Klein, of the Pomerado Medical Group, is very good, knows and understands clusters, and is willing to fight hard and agressively at the first sign of an attack. ;;D

Title: Re: %&*!@ Insurance Companies!!!!
Post by 357Mag on Feb 4^th, 2004, 3:47pm

Clusterbuds,

This one pi$$ed me off BIG TIME. Enough so that I got on the phone and called directly to Mr. Tommy Thompson's office directly. He was in a meeting but I spoke with his personal assistant.

I am awaiting a call so that I can pass along specific details about CH, the problems we are all facing with regards to insurance companies, inept medical professionals, ER visits and the like.

They will be getting the addresses to this and the O.U.C.H web sites and this post in particular. Politicians can tote their horns when it is to their benifit, welllit is time they listen to ours!

I may or may not get anywhere in this quest, but when I set my sights on something, I can usually succeed. All I know is that I have had enough of the bureaucratic BS.

Peace and PFDAN to you all,
dan

Title: Re: %&*!@ Insurance Companies!!!!
Post by manana on Feb 4^th, 2004, 5:58pm

I may or may not get anywhere in this quest, but when I set my sights on something, I can usually succeed. All I know is that I have had enough of the bureaucratic BS.

Me too. We need to speak with one voice to the right people to get the medical profession & insurance co's to work with us so that we can lead productive lives otherwise ... who knows what will happen? Let me know what I can do to help our cause ok?

Title: Re: %&*!@ Insurance Companies!!!!
Post by stevegeebe on Feb 4^th, 2004, 6:11pm

You are going to have to keep on the Doc about this. Sorry.

The Doc has to over-ride the gate keeper at the <a href="http://go-acct.com?go=insurance" onmouseover="window.status = 'goto: insurance';return 1" onmouseout="window.status=''">insurance</a> company.

Same happend to me. But don't expect to get what the Rx calls for. You will only get more than you currently get.

Good luck Toni.

Steve G

Title: Re: %&*!@ Insurance Companies!!!!
Post by t_h_b on Feb 4^th, 2004, 6:37pm

Peteyg, if you have to pay for Imitrex pills out of pocket, get the 100mg even if you take 50mg. You can break them in half and they don't cost much (if any) more than the 50mg pills.

Helpless23, as far as getting your insurance company to approve a higher quantity of a medication, the first step is to have a very specific prescription stating the number of vials/tablets/whatever per month. The pharmacy will do their best to misinterpret any prescription in their favor. I am still having to fight to get ten vials of Imitrex a month out of my insurance company's pharmacy even though I have approval for twelve vials a month. Every time the prescription comes it is short.

A simple letter of medical necessity to your insurance company may not suffice without background information on clusters and a thorough history of your condition demonstrating the need for the quantity requested. Some insurance companies will allow patients to submit information directly or through the MD. I submitted over twenty pages of personal history and research studies in order to get O2 that had been denied. (Whoever read it probably still says a prayer every night thanking God that they don't have clusters.)

I also pointed out that O2 was cheaper than Imitrex and that probably didn't hurt. You might point out that Imitrex is cheaper than ER visits. If your co-pay for an ER visit is cheaper than paying for Imitrex, maybe you can go to the ER a few times to drive the point home.

The initial rejection of your request is knee-jerk. Your goal is to get sufficient information in front of a physician or nurse at the insurance company to convince them to approve it. Your initial request is probably handled by a clerk whereas the letter of medical necessity and supporting information will be seen by a nurse or physician. Physicians and nurses who work for insurance companies are still health care professionals who act as patient advocates: they want their members to get the care that they need. Where I work we even approve things that aren't covered if we know that they are necessary and appropriate--for instance, we approve extra glasses when a prescription changes enough that the optometrist thinks a new pair is warranted or if a kid breaks them. We approve out of network consults for serious conditions on a daily basis.

The rules are different for different insurance companies and for different states, but there should be some kind of internal appeal process, and if that is not decided in your favor, there should be an external appeal process with the state. The appeals are decided on the basis of the information submitted demonstrating medical necessity for covered services. You may also have recourse to filing a complaint internally or externally.

The insurance company may be required to issue a letter of denial, to inform you of the appeals process, and to meet deadlines when rendering a decision on denying a requested service initially and on appeal. There may be expedited processes that you can request. However, you may also have timelines to meet in filing appeals. If the insurance company does not follow the rules it may be decided in your favor on that basis alone.

I hope this information is helpful and I'll check the board in the morning to see if you have any questions that I might help you with.

Cootie, I am confused about your post. If your insurance company requires a $500 deductible each year, and if you use at least $500 worth of services a year, I don't see why it matters to you which services you are paying for to meet your deductible. I may have completely misunderstood what you wrote and apologize if I got it wrong.

Title: Re: %&*!@ Insurance Companies!!!!
Post by t_h_b on Feb 4^th, 2004, 6:51pm

P.S.: even though I work for an insurance company, I still hatethe one providing my health coverage and I REALLY hate their pharmacy. They do have some decent nurses and pharmacists, though. I even had a pharmacist whisper over the phone that he agreed with me 100% but that it was the manager who made the decision.

Title: Re: %&*!@ Insurance Companies!!!!
Post by 357Mag on Feb 5^th, 2004, 1:36am

Bump

T_H_B, glad to see your PS post.

Clusterbuds: I feel this topic to one great importance if we are to get any help, and soon. So I for one am not letting up.

When I did speak to the Department of Health and Human Services yesterday, [going right to the top dogs' office] I let them know that no reply would bring upon them a barrage of calls from me each and every day until they listen.

I hate the bums on Capital hill and dislike playing their game. But I think it is time to take em on! Health care in general in our 'land of plenty' is a disgrace. It is all about lining the already buldging pockets of the insurers, doctors and drug companies. Time to level the playing field.

Won't you all join me in this cause and take a few moments to either call or write your representatives to bring attention to our plight?

Peace,
-dan
PS if anyone has info to pass on or questions you can contact me off-line at hadenuff@kdlltd.com

Title: Re: %&*!@ Insurance Companies!!!!
Post by Cerberus on Feb 6^th, 2004, 1:11am

I agree with Don, attempt the letter of necessity.

as to the pharmacists your doctor can override the pharmacy, He is the care provider NOT the pharmacy and they will cave-in in a heartbeat when threatend by a doctor WHY? Because your doctor can reffer patients to not use their pharmacy. AND, they (as far as I know ) have NO right to trump the physicians method of treatment.......don't quote me on that, but I know of a few instances when a doctor has called the pharmacy on such matters and threatened to take action to have their licences reviewed/revoked for practicing medicine (withholding meds) without legal right to do so. I s'pose its worth a shot. After all ,the meds were prescribed for a reason.

just a thought,
RAmon

Title: Re: %&*!@ Insurance Companies!!!!
Post by t_h_b on Feb 6^th, 2004, 6:44am

Ramon, my insurance company's pharmacy is in Pennsylvania. Because of the problems I've had, I have researched this thoroughly. The law in that lovely state protects the pharmacists and the pharmacies when they dispense the quantity the insurance company allows rather than the quantity the physician prescribed. The law there specifically states:

"This restrictive clause shall not apply.....to reductions in quantities which are dispensed in accordance with limits imposed by virtue of the consumer's membership in a third-party plan."

Pennsylvania regulations governing pharmacies state:

"A pharmacist may decline to fill or refill a prescription if the pharmacist knows or has reason to know that....it is tendered by a patient served by a public or private third-party payor who will not reimburse the pharmacist for that prescription."

http://www.dos.state.pa.us/bpoa/cwp/view.asp?a=1104&q=432995&dsftns=30635

(sections on law and rules & regs)

I'm willing to bet that most states have similar laws and rules & regs. If that's true for you, it means that your MD can only really help you by intervening with the insurance company rather than the pharmacy.

Title: Re: %&*!@ Insurance Companies!!!!
Post by Bob_Johnson on Feb 11^th, 2004, 4:29pm

Two long messages from the archives on dealing with managed care which will give some ideas:

http://www.clusterheadaches.com/wwwboard/messages/31288.html

http://www.clusterheadaches.com/wwwboard/messages/35095.html

Title: Re: %&*!@ Insurance Companies!!!!
Post by randal on Feb 17^th, 2004, 12:04am

If your doctor knows your situation with your drug company and knows you have to pay full price ask if your doctor can give you some free samples of 100MG Imitrex.My doctor gives me 4 or 5 packets a week and I just go pick them up just in case the INS co cuts me off. This way I will have a backup.
Good Luck