A Drop in the Bucket
So your health insurance company won't pay for your life saving prescription?
Many people are being denied coverage for their prescriptions after previously having them paid by their health insurers. so what’s up with that? It’s a growing trend with Health Insurance companies. The drugs that are being denied through their formularies continue to rise each year by double digits. While Cathryn Donaldson, director of communications for America's Health Insurance Plans, the national association of health insurance companies, states that it’s often that the consumer or their doctor doesn’t provide enough information on why they need a drug and just need to go through a simple appeals process where most are successful at procuring the drug; Frederick Isasi, director of the consumer advocacy group Families USA, disagrees. Everyone but the insurance companies would agree there is nothing simple about dealing with their denial process!
Wherein, the drug companies state they won’t pay for diet drugs, or for drugs where one can get a more affordable generic drug. It’s not that simple, they are also denying life saving drugs for which there are no substitutes.
Take into consideration Emily’s situation: *I received her permission to include her experience.
Emily Suess hates insurance companies
You tweeted this message yesterday. I contacted you via email with the requested info, and no one replied. You all could have made this really simple and just fucking approved the medicine my husband's doctor prescribed MONTHS AGO. Don't tell me you're sorry. Fix it.
Molina Healthcare
Replying to @EmilySuess
Emily, we are truly sorry to hear you are not happy with your experience with Molina Healthcare, and we want to do everything we can to help you. Please send us a private message or email your concern, name, member ID#, state & ph. # to MemberServices@MolinaHealthcare.com
Besides Emily’s husband’s situation Emily is being treated for cancer and as of recent her insurance company has refused to pay for her prescription which they previously were paying. They suggested that she try generic medication and other medications. All of them made her horribly sicker. Her doctor and others are trying to help her get the prescribed medicine which was helping her. It’s taking months. She claims she may die in the process.
She is not alone. Recently, I have not been able to pay my electric bill this month because I had to pay to get my heart medication. I had no choice, it was don’t take it and die, or put all I have together and pay the humongous co-pay. Consumer’s Energy suggested I go apply for SSI or go to the Dept. of Health and Human Services. I am not eligible to get help of that kind since my income is over $22,000. yearly. St. Vincent De Paul is a wonderful organization which sometimes helps people in getting their prescription drugs, my cost were just too high. I didn’t even bother to ask.
We are not alone. Last year NPR reported a study was done which revealed that, at least, 29% of Americans had their Health Insurer deny payment on a prescription. Many prescription drugs were previously paid for by the Insurers. The trend seems to be going up yearly. It is expected that Insurance companies will deny payment on prescribed drugs on around 14% more cases from the previous year. Not so surprisingly, more than 50% of those in lower income brackets were unable to fill their prescriptions last year.
A few years back 60 Minutes did a story on people who live in and around the Appellation Mountains on their health care problems and tragedies. There many people could not afford seeing a doctor, let alone buying prescription meds. A couple of nurses purchased an old school bus and drove through the mountains providing physical health services that the people needed badly. Often they would try, with limited success, to provide prescriptions drugs for those who could not otherwise afford them. This area was known to have high incidences of diabetes and many could not afford the medicine to treat it. There was this young man in his late 20’s who worked full-time, but his employer did not provide health insurance. He was a diabetic and relied on the nurses help to get his insulin. He attempted to cut down on his insulin when the supply got low. Eventually he passed away in a short time as he could no longer get any insulin. A sad, but true story. Sadly, a majority of people in that area did not have health coverage, even though, they were working full-time. Due to their low income levels many people survived on a high carb diet and Mountain Dew. They were unable to afford fresh fruits and vegetables.
Currently, coupled with the issues of Covid-19 and people losing their homes, their jobs, and health insurance; health care and prescription drug coverage are needed more than ever. The system is collapsing. People don’t know where to turn. Many people have died needlessly; while others have lost their entire savings and have filed for bankruptcy.
If ever America needed a type of “Medicare for All”, it is now. But, that’s another story. At the end of this newsletter I will attach an article from Consumer Reports which lists available resources to get help in over turning Health Insurance companies denials on paying for prescription drugs. Many times it isn’t cheap. It can cost hundreds of dollars to hire a “patient advocate” to fight the insurance companies. Going to court is another option, but it is usually a last resort and the fees are enormous.
Strikingly scary is that fact that people just don’t have the money to pay for their medicines and they are getting sicker. And, it touches us all, at all income brackets. Even the higher income bracket people making $100,000+ yearly feel the pinch. As many as 18% in the higher income bracket people have not purchased their prescription drugs when their insurance companies refused to pay. One woman who had a cancerous node on her nose would not pay $900. for the cream to cure her cancer. She stated it was fiscally irresponsible even though her income was way over $200,000 yearly. So instead, her doctor was giving her treatment where he was freezing parts of the node on her nose so to delay/stop the cancer from growing.
The middle income bracket people are having difficulty keeping up with daily living costs and there just isn’t enough income to provide for the prescription drugs. People are just doing without.
When a small farm family business was unable to pay for the anti-seizure medication which their young daughter needed multiple times daily, it became a life or death issue. Still at first the insurance company would not pay. But, in this instance they were able with the help of their doctor to get an exception to the insurance company to pay the $2000. monthly bill. But, this was not an easy task. Since they were getting help through Medicare, Medicare has a special formula which demands that an exception requested by a doctor has to have a response within 24 to 72 hours as to whether they will pay the cost of a drug, or not. A lot of paperwork and evidence was needed to prove that the claim should be honored. The family was successful in this instance. But, unlike Medicare many insurance companies do not have this timely claim clause within 24 to 72 hours. Sometimes, people go for months before the exception is approved, or not.
Usually, insurance companies have a lengthy time process in which one has to go through 3 appeal processes before they are approved. Most times, the first appeal is usually denied. The second appeal the insurance company and their doctors and the patient’s doctor collaborate to see if there is good reason to pay on a prescription. Usually the insurance company pushes for trying less expensive drugs or generic drugs. And, there needs to be ample justification from the patient’s doctor for the insurance company to approve payment. On the third appeal an outside doctor will go over the patient’s medical needs and all options available for medications. The patient’s doctor will have to provide proof that their patient could not tolerate generic or substitute drugs documenting that not having the drug which the insurance company refused to pay on would cause significant harm to the person.
When insurance companies tell you they have patient advocates, don’t believe them. The companies hire people to save them money and not pay on claims because it is their bottom dollar that they care about. And, the price of generic drugs is steadily going up as well. It is expected that by 2022 the price of generic drugs will have gone up by 18% from the previous year.
The best thing for one to do is not wait until you only have 1 or 2 pills left of your prescription (as I had done). Check early to make sure everything is set at your pharmacy. Talk to your doctor about providing an exception letter which documents why other medications would not work for you and why you need your drug and how it benefits you. If you are denied, don’t wait, appeal asap. It may take up to 3 times to finally get approved. In the meantime, you may want to solicit St. Vincent De Paul’s to pay cash for your prescriptions, or contact the “Needy Meds” program and ask for assistance. If you are on Medicare, you may have the good fortune of their assistance in asking for an “exception” which in most cases is done within 24 hours. Also, there may be a health ombudsman in your State which you may want to contact through the Dept. of Health and Human Services.
If you’re having problems getting your health insurer to pay for your prescription drugs and you want to know more there are some periodicals and studies to give interesting and, hopefully, useful information at the bottom of this newsletter.
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Healthy Days, Healthy Ways
Take the time to relax
Let annoyances roll of your back
See the sun and sky beyond
Take deep breaths and overcome
Cool your head
Go earlier to bed
While going to sleep
Think of promises you should keep
Go over things which you are thankful for
And, give it up to God if a problem won’t leave you
Wake up with nothing to grieve you
Share your smile and a cookie, or dollar, or umbrella if you can
And, wait and see as the day moves on appreciating every step of your journey and beyond
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https://www.consumerreports.org/prescription-drugs/when-your-insurer-drops-your-prescription-drug/
https://www.npr.org/sections/health-shots/2020/01/27/799019013/when-insurance-wont-cover-drugs-americans-make-tough-choices-about-their-health
https://www.needymeds.org/
https://www.jdrf.org/t1d-resources/living-with-t1d/insurance/insurance-denials-appeals/
http://www.neuropathyaction.org/patient_resources_news/insurance_company.htm
http://pharmacisttips.com/prescription-insurance-plans/prior-authorization-how-do-you-get-insurance-companies-to-approve-medications/
http://pharmacisttips.com/prescription-insurance-plans/prior-authorization-how-do-you-get-insurance-companies-to-approve-medications/
Lucy! You are doing some first rate muck-raking! Well done! And thank you for the links!