60% Good News

This morning the news I got was 60% good. After posting about the problems with getting my prescription now that CVS Caremark is administering our prescription coverage I got some really great advice from my readers.

I started with a very long phone call to my State Insurance Commissioner. During the phone call they detailed for me the process of filing a complaint, which begins with contacting the plan administrator. The plan administrator was extraordinarily kind. So much so that when I detailed the series of events I ended up crying. It was the first time anyone had been remotely sympathetic to me.

The plan administrator called me back promptly on Friday and left a message letting me know she had an update, but I wasn’t home all day Friday so it wasn’t until this morning that I was able to return the phone call.

The Plan will reimburse me 60%. I will get approximately $1,200 back, and the other $800 or so dollars will be mine to pay. I will continue to use the mail order pharmacy or be required to pay cash (which is not really an option).

I’m not sure if I should be happy with this. $800 is a lot of money to pay, but $1,200 is a lot of money to be reimbursed. I’ve spent nearly 20 hours on this, and I’m not convinced that 20 more hours would get me the $800 that I feel is due to me.

What I do know is that insurance isn’t designed with health in mind. If it were then physicians would be able to prescribe patients the best drug for their disease and patients would have immediate and unfetterd access to the drugs that can arrest their diseases. Rheumatoid Arthritis is not the common cold. One third of RA patients end up on disability within a few years of diagnosis. That number is a number that has been steadily dropping due to the discovery and manufacture of biologics like Simponi (the one I take), Enbrel, Humira and Orencia. These are not inexpensive medications, but they are far more economical than visits to specialists for pain relief and (sometimes permanent) disability.

No one can tell me that our current system makes fiscal sense.

My readers (bless you all) have been so kind and helpful, emails have detailed for me how to work within the system. Until last August I never understood that a system existed, and I worry terribly for people who would have to wade through telephone trees and piles of paperwork all the while feeling ill and trying to keep their jobs. It’s simply unteneable.

Again, I’m not sure if this is where it ends for me, or if I take the next (rather exhausting) step and bring civil action.

I have been in contact with the mail order pharmacy and I was left speechless when the operator (pharmacy tech possibly?) was unable to pronounce simple words. After I listed the drugs that I am allergic to I waited for him to ask me what prescriptions I’m currently taking. The question didn’t come. Someone other than CVS will have to protect me from the possibility of a drug interaction, a real pharmacist perhaps.

I’m sure I’ll be okay because I have an amazing local pharmacist and a two of the most talented and devoted physicians a patient could hope for, but it will be in spite of CVS’ mail order pharmacy, and not because of it.

 

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Comments 6

  1. Insurance. Pharmaceutical companies. Regulatory Agencies.
    None are on the side of *fixing* the problem – all are on the side of keeping themselves in business.

    Doctors would probably like to cure patients. But if you’re cured, then why would you need to keep buying $2k/month prescriptions? And if you didn’t need to buy those, why would you need to pay insurance premiums? And if you don’t need drugs that treat symptoms only and insurance companies that pay for the least expensive solution, why would you need to have an agency that regulates them?

    We are expecting companies and agencies that rely upon *not* fixing the problem in order to stay in business, to fix the problem. Why in heaven’s name would they do that?
    :(

    1. p.s. have you looked into the whole “anti-inflammatory diet” thing? I’m looking because my doc mentioned a friend of hers – physician & marathon runner – who got diagnosed with RA about 2 years ago and had gone with one of them based on the science and has found *significant* relief.
      I’m looking into it.

  2. Pingback: Why I’m not Fighting Rheumatoid Arthritis

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