HMO Mentality: Long

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Posted by Katherine ( on June 21, 2001 at 12:07:54:

In Reply to: Imitrex posted by Bob P on June 21, 2001 at 09:55:48:

I can not give you an official explanation from my own HMO (because if I did that I would get in trouble) so let me give you my opinion as someone who has worked in the industry for the last 5 years.

An HMO likes to pay for things that are effective and efficient. That means both medically effective and also cost effective. This is why an HMO will not pay for experimental procedures, because experimental procedures can not be proven to be medically effective to help correct the problem, to say nothing of their lack of cost effectiveness. A chance that something will help you is not good enough for the HMOs. A procedure or a drug needs to be proven to be an effective treatment. Then, even if it is hideously expensive, an HMO will pay for it, because they expect that they will only have to pay for one treatment, rather than 4 or 5 different attempts to fix the problem before a solution is hit upon. Efficiency, get it?

So taking that as a model, examine the problem with Imitrex

1. Imitrex is hideously expensive.
2. It is known to work efficiently for Migraines.
3. An HMO will pay for it for Migraines.
4. Most migraine sufferers don't need it more than 6 times a month.
5. Therefore that is how much an HMO will cover.

If you note the logic in the above you will realize that the logic is not that an HMO will pay for Imitrex, it's that an HMO will pay for Imitrex for migraine sufferers.

But you and I are not Migraine sufferers. And if you are going to fight them on this, then that is the logic that you will have to use to get them to shell out for more.

I suggest you contact your customer service area of your HMO and ask to appeal the policy that the HMO will only pay for 6 injections a month. The appeal process usually takes a couple of weeks, so start early in your cluster (or before your next one!) and stress the urgency to the customer service rep or even better the customer service supervisor. Be nice to them, since they will be much more willing to help you if you are not screaming at them, but do not take no for an answer. There is always an appeal process. Your neurologist will need to give supporting documentation to your HMO's policy department that a) Imitrex is an effective and standard treatment for Cluster Headaches, b) documentation on clusters, since even most nurses I know have never heard of them as well as c) clinical documentation that Imitrex has been an effective treatment for YOU. Usually anecdotal information is not enough unless you get to a level 3 appeal.

Basically you need to prove that the dosage maximum that the HMO has set is not accurate for the type of headache that you have, and that they need to make an exception for you. It would be better if they changed the policy itself to make an exception for cluster headaches across the board, but usually that does not happen except through some kind of state or federal level mandate, like is done in Massachusetts for in vitro fertilization.

Things that may work against you:
Lack of documentation about Clusters. Lack of funding for research: In both these cases because there is so little out there about it, an HMO may decree that treating clusters with more than 6 doses of imitrex a month is experimental and they will not pay for it.
Chronic condition: I hate this part. Check your plan documents. Look for what the HMO's will pay for a "chronic condition". In many cases an HMO will not pay for claims that are associated with something that is not life threatening but ultimately can not get better. If you are shown to be a Chronic sufferer rather than an episodic sufferer, the HMO may not pay for it at ALL. Why? Because an HMO is interested in medical and cost effectiveness. Anything that involves throwing money away on something that will never get better is neither effective nor efficient. So be careful in your appeal, be very careful. Underline that Imitrex is effective at relieving the individual headaches and significantly improves your quality of life.

I know that is not fair, but does that answer your question? Does it give you a weapon that you can use?
Please remember that the above is my opinion only and needs to be taken as such.

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