Down With Hmo's!!!!!!!!!!!!!!!!!!!!

I have flat feet, Morton’s Neuroma, bad tendons, to summarize, I have bad feet. I can’t stand for more than 15 to 30 minutes without my feet hurting. After about an hour, it’s almost unbearable.
A while ago, my podiatrist gave me samples of Bextra, an anti inflammatory, which, unlike two other anti inflammitories which I tried, actually works. I can stand longer, and when my feet do hurt, I can usually ignore it.
I use the pharmacy at Wal-Mart, and am using my wife’s insurance, Regence Blue Cross Blueshield of Oregon. They won’t pay for the Bextra. It’s too new and isn’t a part of their regular formula…or some shit like that, I don’t remember the exact reason for the denial.
Ok, no problem, this year, I got insurance, CIGNA, through where I work. The podiatrists office told me that Wal-Mart won’t bill CIGNA, and if I find another pharmacy that does take CIGNA, chances are they won’t approve it either.
Not only that, the orthotics I have made (arch supports) need to be updated about every two years. My wife’s insurance won’t cover it, but thankfully mine will. However, I’m trying to get a new job, and I’m even trying for the State, where my wife currently works. If I get a job there, then I’ll get Regence and be screwed when it’s time to update my orthotics.
My wife’s insurance also turned down a prescription for her, Celebrex, because they only cover it for people over 55.
If I were upper middle class, or rich, this wouldn’t be much of a problem, but for middle-middle class or lower, having to pay $80 for a prescription (Bextra) is a huge deal.
I can’t believe I pay…somewhere around $50 to $60 a month, only to get turned down, for something I NEED.
Anyway, I hope that the HMO is a passing phase and will go away soon. Of course, if not, I’d love to be part of an effort, to force it to go away.

Sorry about your feet, but what do HMOs have to do with all that?

I’ll trade you your HMO for my state of uninsuredness.

First, there is nothing wrong with gay people. Second, the term you used, “homo,” is…ummm…


Is Blue Cross Blue Shield an HMO?

It can be.

I’ve got Blue Cross, and I’m on their HMO plan. But we also have a PPO option.

I rue the state of healthcare today. I got a referral to an allergist last week. Called up this morning, was on hold for 5 minutes before someone picked up to schedule an appointment. First available appointment was April 10th.


Well, do people want their cake, or do they want to eat it? If you want government interfering in your health-care, then you have to put up with unintended consequences like misallocations and shortages.

Joel, have you asked your insurer to make an exception and cover the prescription that works for you?

Lib, I didn’t know that the government interefered with formulary decisions. I thought that HMOs covered drugs based on considerations such as cost when there is more than one drug available in the same class. In what way do you think government is interfering?

Joel, I’m sorry about your current problems. I’ve got a lot of the same problems with my feet, and it sucks a lot.

That being said, your insurance issues aren’t out of the ordinary. Most insurances won’t cover very new drugs, because there are already a lot of similar drugs out there that basically do the same thing as Bextra. I know, I know, the Bextra works and the two you’ve already tried won’t. But there are lots of other anti-inflammatory drugs out there, and you can probably try something from the same family to see if that works. Even if they won’t cover that, there are still LOTS of other anti-inflammatories, and you may have to play Medication Roulette until you find something that works.

And, as for the Celebrex for your wife, find out if Vioxx would be covered. It’s a similar drug that’s also widely prescribed. Some insurance companies will pay for one if they won’t pay for the other.

As for the orthotics, consider yourself lucky that you’ve got insurance that’ll pay for them at all. The only insurance I’ve ever had that will cover them was Blue Cross for federal employees, and that’s only because it also covers postal employees who work on their feet.

Other than that, all I can say is, sorry about your luck. Yeah, it sucks, but the insurance you’ve got is better than none at all.




I have one of the “Blue Cross” HMO systems too, and I’m desperate to ditch it. My migraine medication costs $35 per month–for three pills, of which I’m supposed to take one every time I get a migraine. I am not allowed under the HMO to get any more than three pills per month, even if I pay $35 more. Needless to say, I get more than three migraines a month, so I’m shit out of luck when I hit Migraine #4.

Now, I am sure HMO defenders will say “Those pills cost more than $35 for three!”, which I know is true (a friend a rival drug company thought the actual cost was something like $60-80 if I bought them direct from the company, which of course I can’t). I present you with these questions, then: 1) What is the HMO doing with the $800/yr I pay them, and aren’t they getting a better group discount from the drug company? 2) Why won’t the HMO let me have more than three pills per month, when both my primary care physician and my neurologist have petitioned them for at least six? 3) And most damning, how come the rival HMO, which I’m desperate to switch over to, has the same annual fees and I’d be paying less for six pills with them?

I won’t even ask question 4) Why is your CEO a multi-millionaire?, because I am sure some “pure capitalist” will come along and tell me.

You know, I don’t have all the answers. (You’re shocked, I know!)

What I do know is that our health care system could be better. I’m convinced that it could be. I also realize that it could be worse.

But that doesn’t mean we can’t bitch and moan! Please!

But seriously. We need to fix this. It ain’t getting any better.


If Bextra isn’t on the formulary, Vioxx or Celebrex might be. It’s very rare that one works for someone and the others don’t.

Most of the time, though, we have to document (and usually send a letter to the HMO saying) that you have failed other, cheaper NSAIDS before they’ll pay for a COX-2 inhibitor. Similarly, if Bextra is the only COX-2 inhibitor that works and it isn’t on the formulary, a letter from your doctor may get it covered.

As a last resort, if Bextra is the only thing that works and your HMO just won’t pay for it, contact the company that makes it; they often have indigent patient programs. They may be especially lenient or willing to make an exception in a situation like this where it’s a formulary problem; they’re probably trying to get on formularies (since it is a fairly new drug), and they’d hate for you to have switched to Vioxx before then.

(Standard medical advice disclaimers apply.)

Dr. J

I’ve worked with benefits (HR) for years, and I second (third?) the suggestion that you petition your insurance company to make a formulary exception for you. The squeaky wheel (the one that calls them every week to find out the status of the exception) sometimes gets the grease.

Good luck - I wish you much grease. :smiley:

They won’t pay for pills I need to be able to stand without pain. My wife’s won’t pay for orthotics I also need.
And my podiatrist recomended getting some theropy for my feet. I hope I don’t run into any insurance problems with that either.

No, I just found today that I was rejected, that’s why I ranted. I’m thinking about it, but I don’t know if it’ll do any good anyway. Our (My wife’s and my) tax returns are comming in soon. I should be able to use that to buy the pills if I can’t get insurance too. But after I get the new orthotics, and foot theropy, if I need the pills again, well…

*Originally posted by MsRobyn *
Even if they won’t cover that, there are still LOTS of other anti-inflammatories, and you may have to play Medication Roulette until you find something that works.
Yeah, I may have to end up doing that.

Yeah, it’s been a little while now. There was something different about Celebrex compared to the other similar drugs. Something that it doesn’t have that some people are alergic to…or, oh, I can’t remember the difference.

Yeah, I am glad I have coverage for that. Well, they pay 80%, but that’s not too bad. Before, the previous insurance my wife had paid most of the bill for the first set I bought. But I’m going to need to get new ones about every two years because of bad tendons, I think it is, in my feet. I just have to hope that years down the road I have insurance, or make better money in order to continue to get them.

True, in this current system, having it is better to have it, but I’m hopeing that a whole new system will eventually take over. But I know, I know, I’m probably just dreaming. :slight_smile:

Thank you for the info. I’m strongly thinking of sending a letter to the HMO. I don’t expect much, but I may try.

Thank you.

Yeah. Real bummer, that I can’t get my teeth fixed and at the rate I’m going, I’ll be wearing dentures by the time I’m thirty.