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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 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 a realistic 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 was never designed with health in mind. If it were, physicians would be able to prescribe patients the best drug for their disease, and patients would have immediate and unfettered access to the medications that can best 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 untenable.

Again, I’m not sure if this is where it ends for me, or if I take the next (rather exhausting) step and bring a 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 a fantastic local pharmacist and a two of the most talented and devoted physicians a patient could hope for, but it will be despite CVS’ mail order pharmacy, and not because of it.