Medical follies

The BBQ Pit
1

Grr. There are many medical things going on in my life, but this is the one I’m moved to place in the Pit just now. There may be another rant/question going into a different forum later on.

Background: My body makes no insulin at all. In 2023 my doctor put me on an insulin pod. This was a game changer. I went from seven insulin injections a day to one insertion of a pod every three days: from about 2400 injections a year to about 50 pod insertions a year. It worked, and it was great, and to say that I was happy would be a severe understatement.

Soon afterward I was prescribed a Dexcom constant glucose monitor. Previously I had done at least five finger sticks a day; now I applied a new CGM once every ten days and things were again way easier and way better.

And they remained better, until last week, when I discovered that my insurance company was no longer covering the insulin suitable for use in the pod. Now it was only going to be covering insulin in pen form such as I’d had four years before. (How did I find this out? Because my pharmacy didn’t refill the prescription for me. Did the pharmacy tell me why not or what was going on? Yes, three days later, when I called them wondering what was happening. “Oh,” they said, “you need a prior authorization from the doctor….” Thanks for letting me know, guys.)

So I called the doctor, and to the credit of his office he and his staff got a prior authorization right off to the insurance company. Which called me the next day to tell me that the authorization had been approved and I would be able to get the insulin for the pod. Which I picked up at the drugstore later that afternoon. So, bullet dodged. Right?

Right?

Right! Until yesterday, when I discovered—and I really should have seen this coming—that my insurance company was ALSO no longer covering the CGM. Which I found out because my pharmacy didn’t refill THAT prescription. Not that they told me this time, either. Okay, I called the drugstore, found out what the deal was, confirmed that the insurance co was truly expecting me to return to the bad old days of constant finger sticks, called the doctor’s office, spoke to the same person who had done the prior authorization for the insulin, and was told an hour later that everything was set, we were only waiting on the signature from the doctor…

That was Thursday afternoon. I called the insurance company for an update on Friday late morning. They didn’t have the documentation. Why not? We tried calling the doctor’s office, but it was closed—closed all day Friday, their voice mail message said. My guess is the doctor never signed the form, secondarily that he did but late enough that it didn’t get faxed. Either way, I got screwed.

As I write this, the CGM is expired and in its twelve hour grace period, and I don’t have another one, and insurance and physician offices will be closed over the weekend and possibly through Monday, so it’ll be finger sticks for the foreseeable future—and no alarms should my sugar reading fall too low or go too high. (Neither of which is out of the question for me.)

I guess it’s not the worst thing in the world. I’ve survived finger sticks and I am sure I can do it again. But good Lord, who thought it was a good idea to stop covering things that actually helped? And can’t anyone here get it right?

2

Good grief, that sucks!

3

I know your question is rhetorical, but the answer is simple:
Who? Someone who looked only at which was immediately cheaper for the insurance company: insulin pods & CGMs, or finger sticks & single use pens.

Long term morbidity reduction through better glycemic control and improved daily quality of life from reduced fiddling with staying alive every 2 hours? Simply. Not. Relevant.

Our country sucks in so many ways.

4

Definitely. I am now an ostomate, and insurance had been paying for my supplies [2 part ‘wafer system’ of a base plate and a bag, adhesive remover wipes, and some parentheses shaped strips to adhere the base down along the edges better] at about $6 per ‘change’ allowing me a change per day. My copay being something along the lines of about $100 a month. 3 month supply. Every damned quarter there was some hold up, insurance not authorized, something out of stock can we substitute some random product, for 3 years NOTHING went smoothly.

Got to about a year and a half ago. Down to my last 4 bag changes. Insurance stalling me - we need a doctor signature, Byram out of stock, and I admit I experimented with medical tape and a cheap baggie to see if it would work [it mostly does]

In desperation, I hit Amazon to check on pricing for the convatec bag sets I used. Yay box of 10 wafers, $70, bags $30 box of 10 … hmmmmmmm some off brand Chinese bag [one piece not 2 part] a freaking DOLLAR PER BAG. So off goes an order for a box, I figure if nothing else, emergency supplies on hand after my regular [hah] order gets straightened out.

Haven’t gone back. Yes, they are sort of more crinkly sounding, but the seam welds are solid, the adhesive sticks and best of all, peels off without the adhesive remover and they simply WORK, no muss, no fuss, no faffing around [well other than having to trim the holes to my specific diameter] and I now keep a year supply on hand, reorder every 3 months to top off my stash. AND NO FUCKING INSURANCE COMPANY OR SUPPLIER SCREWING ME OVER. Amazon don’t care if I have a doctors signature, Chinese factory doesn’t give a shit [giggle]

By the way, to tide one over, one may buy Stelos by Dexcom without a prescription at like $50 per sensor. If nothing it can tide one over.

5

Every 8 weeks I get a monoclonal antibody infusion to treat ulcerative colitis. It works great; I’ve been in remission for over a decade. Every year when my insurance renews I have to get reauthorized to get the infusions. Same insurance each time, and they’ve never pushed back on approval.

The problem is time. My doctor puts in for approval immediately after my last treatment of the year, and sometimes the insurance approves it right away, and I resume treatment on schedule in the new plan year. Other years the insurance refuses to accept the reauthorization until the new year starts, and I fall off the schedule.

This last time was particular bad. I ended up about 4 weeks late for my treatment, which was enough to start sliding out of remission. Fortunately symptoms went away when treatment resumed.

I tried to schedule my treatments this year so my last one is as close to the end of the year as possible, but there is only so much slop in the schedule, so I still risk a gap in treatment.

6

Thanks, @needscoffee . @LSLGuy , you’re right, of course. @aruvqan_myers and @echoreply , sorry but not surprised that you’re running into similar stuff. I like the creativity in post 4!

There’s an update. I called Dexcom, the maker of the sensors, this morning to see if they might give me a voucher for a free off-the-insurance-books GCM. They have done this in the past when my sensors have failed (which is not often) and spurred on by my sister I figured it was worth a try: sob story and all. We were right! Dexcom was very happy to email me a voucher given everything that was going on, and off I went to the pharmacy to pick the new sensor up. Case closed!

…Until I got home and installed the new sensor and discovered it would not pair with my phone. Called Dexcom again. They tried a few things on their end; no dice. Eventually they sent me yet another voucher. Back to the pharmacy I trundled. Picked up the (second) new sensor. Brought it home, installed it, and waited with trepidation–

Well, this one paired just fine. Phew! But I’m still waiting for the other shoe to drop.

You can’t make this stuff up. Or rather, you should ONLY make this stuff up.

7

DM type II. Some years ago – before it became trendy – my doc put me on Ozempic to help get my A1C down. This has worked splendidly. I haven’t noticed much weight loss but it’s doing it’s bit to help my blood sugal levels stay down, so both me and my doctor want me to stay on it.

A couple of months ago I got a letter from my insurance saying they will only fill Ozempic on a 90 day cycle. That is more than OK with me as fewer trips to the pharmacy will make my life marginally easier. I called my doctor and asked them to write a new script for a 90 day fill and had them send it over. Then I took the letter to my pharmacy and the pharmacist, who I know personally, simply refused to fill it on a 90 day cycle. He said that he doesn’t like filling any refrigerated meds for 90 days as too many of his customers lose them or they fall out and break or whatever.

No whatever. My doc ordered a 90 day supply, my insurance will only pay for a 90 day supply, so fill my prescription as ordered please and thank you.

No dice.

I had had some issues with that pharmacy before, specifically with filling my insulin. They refused – or perhaps simply neglected – to run the script through as written, choosing instead to try to fill it with the generic only and the insurance came back needing a PA. When they ran it as written, using the name-brand drug (Lantus), it went through with no problem. So after the Ozempic thing I was done.

That very day I transferred all my prescriptions to Costco which so far, knock on wood, has been easy-peasy to deal with. Admittedly, they haven’t had to fill the ozempic script yet but I’m going in today for a hearing test* and will check and see if they have the current 90 day script and whatever else they need to fill it when the fill date comes around.

I hate the U.S. medical system.

* Oh yeah. I need hearing aids, badly. I’m only 45 and have had noticeable hearing loss for ~15 years. It has, predictably, only gotten worse in that decade and a half. I’m sure this will be a whole 'nuther nightmare. Although… since I won’t be dealing with insurance for any hearing aids I’ll be getting, maybe it’ll go much smoother than getting my life-sustaining meds.

8

That’s when you offer to take it to a different pharmacy.

ETA: Whoops, you ninja’d me.

9

My wife’s doctor prescribed her something that is available as a cheap generic, and the insurance made a big fuss, wanting pre-authorization and submit a whole bunch of documentation and stuff. Turns out if we get it from Costco without insurance we save $10 for a 90 day supply. Had the doctor transfer the prescription and just got on with our lives.

Same drug insurance, Caremark to name names, is bizarrely aggressive with mail order renewals. Similar to @Lancia, for maintenance medication we have to get a 90 day supply through the mail order pharmacy.

About 60 days into the 90 day period Caremark sends a text to see if we want more drugs. Sure, why not? Most of them have a $0 copay, so it doesn’t even cost anything. The pattern now is whenever I open a new 90 day supply, I order the next 90 day supply. Feels weird complaining about too generous of coverage, but I really don’t need a 2 year supply of statins taking up room in the medicine cabinet.

More Caremark fun! One of the drugs my wife takes is in short supply. She is supposed to get 90 pills for a 90 day supply at 20mg each (or whatever dose). That isn’t available so instead they sent 180 of the 10mg pills. Absolutely no big deal, and if they’d just sent a message saying, “hey, this is what your getting,” nobody would have stressed at all.

Instead they sent paper letters and emails about the prescription being cancelled, and at the same time sent emails about the order being processed. These processed and declined and processed and cancelled and preparing to ship where all intermixed, so we had no idea what was going on until 2 bottles arrived instead of 1. They did the right thing, just very poor communication.

10

There have been several threads here about hearing aids. Costco is considered one of the better places to get them, price- and quality-wise.

11

Nosy question: Was this due to any workplace noise issues? I’m curious if workers comp might cover it from that far back.

12

Or the military. The US VA is a total pushover to declare hearing loss to be service-related. Especially premature hearing loss. That leads to free hearing aids, free hearing care, and some cash stipend per month.

13

In other words, modern medicine itself has been great news for you, and you just have a problem with the American coverage-denial industry. Why we even have a coverage-denial industry, I couldn’t tell you, but it’s hardly a surprise that it causes problems.

14

Coverage-denial industry - that’s a great description.

The US medical coverage system is a horrible, inefficient, unnecessarily complicated need that doesn’t serve the needs of patients or caregivers.

Let’s start with the description “insurance”. For most people, or isn’t insurance, it’s a medical payment assistance system that may have catastrophic insurance as part of it. It’s often a benefit from work, with them providing partial payment to the “insurance” companies to reduce the premium costs. We see how well that’s working out.

Which is the second biggest complaint - most of us have our Healthcare assistance plan linked to our jobs. It’s nice they pay some of the cost, but we are typically stuck picking between one or two options, neither appropriate for our needs. And if you change jobs or lose your job, you lose your Healthcare plan. And even if you stay employed, you still have to look annually to re-signup for coverage. Sometimes your company arbitrarily changes optins and your forced to choose a new plan.

Ok, so you get healthcare. Your coverage is determined by various other parties not interested in giving you the best care, they are interested in their bottom line. Cheap out and only cover this “acceptable” option because the premium - i.e. best - option costs them more.

Then you come to the Healthcare providers’ side. They get forced into large conglomerates in order to participate in getting paid by various coverage companies. And the rules for each are vastly different. Even within the same coverage company, the coverage payment for each patient can be different even if from the same employer.

The industry is so complex, it’s created a whole industry dedicated to trying to get paid. Filing and refiling forms, trying to get more networks that they can get paid by. And how much they can get reimbursed for any procedure can be different and not stated to them upfront, so they set procedure prices arbitrarily high to make sure they get maximim reimbursement.

Doctors hate it, nurses hate it, patients hate it. And if you have a medical procedure, you as the patient somehow have to ensure everyone that works on you is in-network, or your pay more. Except the patient has no control over the staffing or who is needed. It’s not like you get a list of every possible person and get to mark out any that are out- of- network. But the providers put legal language in your contact that they are not liable if some out- of- network person is involved.

It’s crazy.

15

If I’d continued my practice, I’d have gone to cash only. Way too much time spent resubmitting my (correct) bills for payment.