What part of "Treatment for a medical condition" don't you understand?

The BBQ Pit
1

I have endometriosis. It’s a sucky little condition that attacks my ‘woman parts’, and to put it nicely, it feels like someone is trying to pull my uterus out through my belly button with a pair of pliers most of the time. Every month, I used to be laid up for two days, throwing up and curled up in the fetal position from cramps.

Finally, my new gyno has actually found something that works for me. She prescribed a new BC pill that I take for three months in a row - in other words, I only have a period four times a year. My pain has decreased by 75% and I feel better than I have in years. While I use the pills for birth control as well, they are primarily for my condition - we use a separate birth control in addition to the pills, and would continue to use this should I go off the pill.

So I took the prescription to the pharmacy to be filled for the first time about five months ago. My doc wrote on the prescription that I could get three packs at a time, since that would last me a little over two months. First I tried to just get the prescription filled - for that, I needed authorization from my doctor for the insurance company. What-the-fuck-ever. I need authorization for birth control pills, but I’m sure if I’d walked in with a prescription for Viagra, I wouldn’t have had a damn problem. So my doctor faxes over the authorization in a couple of days. Wonderful. I try to get the three packs that she’s prescribed me. Now the insurance company is saying that I can only have one pack at a time.

And because they’ll only pay for one pack a month, I’m faced with a choice. Take the pills in the regular way and basically suffer again, or pay out of pocket to get medication that I need. My doctor faxes yet ANOTHER authorization to the insurance company telling them that the BC is for a medical condition and that I MUST be able to take it continuously. They give her a big ol’ hearty Giant Corporation Fuck You.

I’m on my own. For a few months, I just waited until the last possible second to get my BC and it was usually approved because it was close enough to the end of my prescription. However, it’s finally caught up with me. They refused to pay for a refill at the time I needed it - they said they would do it in four days, but unfortunately, four days was four days into my prescription and I can’t skip pills for more than three days (even that isn’t recommended). So I ended up paying out of pocket for my medication.

I just don’t get it. We proved to them that it was a medical condition, that I’m not trying to put one over on them just to get more pills…I mean, hell, it’s not like these things are Ecstasy or anything. So apparently, my insurance company would prefer to pay for my laparoscopy to scrape the lesions out of my uterus, or pay for the birth of a child, than pay an extra $30 to let me have my birth control on time. And no, $30 is not going to break the bank, but after just paying moving expenses and being unemployed at the moment, $30 is more than I’d like to spend. And I can’t continue to pay $30 every time I need my pills (and this will continue to happen for awhile now).

So to the insurance company that doesn’t really care if their customers are in pain or able to take their medication on time, I hope that one day, you know what it feels like to be in immense pain and not be able to get the medication you need, or that your insurance company denies you for it. Having endometriosis is not fun, and it’s stressful enough as it is to not know whether or not we will eventually be able to even have children - $30 is a small price to pay for continuing my treatment, but $30 is nothing to you.

Ava

2

Ask your Doc (or her advice nurse) for some “sample” packets of pills to tide you over while the insurance company pulls its head out.

Good luck.

3

I 2nd The Devil’s Grandmother’s recommendation to ask your doctor for sample packets. My doctor used to give me all my pills from his sample stock – I think I only had to pay out of pocket for pills once or twice in my life.

I don’t know if you’re anywhere near a border town, avabeth, but if you are, consider spending a weekend in Mexico and picking up your pills at a pharmacy there. The U.S. market is such a damn ripoff. When I was living in Puerto Vallarta I was paying – are you sitting? – $1/month for the exact same pills by the exact same manufacturer that would’ve cost me over $30/month if I’d’ve had to pay for them in the States. You don’t even need to show a prescription, as they’re sold “over-the-counter” (though they have to be dispensed by the pharmacist – they aren’t just sitting out on the shelves).

I have no knowledge about the legitimacy of this website, but there’s an online pharmacy that ships from Mexico, called MedsMex.com. I don’t know what pills you’re taking, but as an example, the Nordette 21 pack is $10.95 through their site, whereas drugstore.com wants $33.47 for the exact same thing.

Good Luck, and I’m glad you’re feeling better!

4

Another option – short-term, at least, while you fight the insurance company – might be Planned Parenthood or a similar entity. I get my pills (as well as exams and all) from them at a discount.

[girly hijack]Speaking of which, it’s getting to be time for my annual. Oh, ICK.[/girly hijack]

5

Thanks for the advice! Honestly, I don’t know what else I can do with the insurance company other than what I’ve done. And hopefully, I’ll have a job soon, so being able to afford this shouldn’t be too bad. My fiance has offered to help me out with it, too - since this is really our future in trying to have a family that it’s affecting. And hopefully, a new job will bring different insurance - I’ve heard of a few in Ohio that seem to be good, so with luck, this won’t be a problem.

It just seriously frustrates me that they would withhold someone’s medication like this. And not just mine - what about the elderly’s heart pills? The pain isn’t going to kill me, although it’s certainly difficult, but not taking a heart pill would definitely have an effect on an elderly person.

Ava

6

I feel for you, avabeth. I don’t understand this policy, either. I’ve run into it when I was on the pill (using it for contraception and wanting to avoid the hassle of having to go to the drugstore every month).

Why the fuck is that??? I take anti-depressants, and have a prescription for 3 months, with 3 refills. That’s one whole year of anti-depressants! And nobody has ever said boo.

Fucking fucktards.

7

It’s not just BC pills for which insurance companies try to play doctor (although a former co-worker had the exact same issue you are having, and had to threaten to report them to whatever stae agency regulates insurance companies to get them to behave themselves).

When I had leg surgery a few years back, I had complications: deep vein thrombosis. I had to take coumadin (blood thinners) for months. Coumadin is a very difficult drug to monitor and regulate; they were taking blood samples every couple of days to make sure I wasn’t either going to have a stroke, a pulmonary embolism, or bleed to death. The dosage needed to keep me regulated could vary from 1 mg/day to 10 mg/day, so obviously I haad to get 1 mg pills and possibly take several at a time, and it was impossible to predict how many I’d need in a month.
No matter how many times my doctor called and yelled at the pharmacy, they just couldn’t seem to figure it out. And it was really a pain in the ass, because I couldn’t walk (I could barely stand up on crutches for 30 seconds at a time, I was so weak), so half the time I’d send my mom or my boyfriend or someone to pick up the prescription for me, and they’d come back empty-handed and have to try again the next day.

Good luck, and don’t take any crap! Besides, wasn’t there just a court case that if a plan covers reproductive health care/prescriptions at all, they have to cover contraception?

8

You know, I can at least understand why an insurance company would want to deny coverage for something that costs them a lot of money, but I don’t understand, as you point out, why they would fight so hard against something that will save them money in the end.

I ran into the same thing when I had my daughter. We had to very carefully search for a new provider that would actually cover my delivery at a birth center. Everyone covered a hospital birth, 100%, including that perennial money-maker the epidural, plus a couple days being cared for round the clock, getting meals from the hospital kitchen, getting $10 Tylenols and so on. But would they cover a delivery with no anesthesia, no surgery, and no overnight stay? Of course not, that would make too much sense.

I like the idea of asking your doc for samples. At this point, it’s probably a much easier job for her than trying to knock sense into the insurance company.

9

Ava, are you on Seasonale? It’s the new birth control pill that you take continuously for 12 weeks, with one week off, when you get your period. That is what I am on. It came out recently, so I asked my doctor for it, then took the prescription to the pharmacy and right away they said they had to contact the insurer for authorization. I was like, “oh great, this sucks.” But I got it, they approved it! I was pleasantly surprised.

My insurer is the same way, only allowing you to refill one month at a time. Back when I was on the mothly dose of BC pills, I could only get one pack at a time (same with my other medication). So I had to go to the pharmacy every month to get it, which is a major pain. I would much rather get three packs at once and save the trip.

I would highly suggest calling up your state’s department of insurance and inquire about making a complaint. You might be surprised, your insurer might back down when faced with a complaint.

One more unexpected benefit. With Seasonale, you get three months of pills in one pack. So I only have to get it filled every three months. I save money too: I pay a pre-set copayment on each prescription, so I pay $20 for a three-month supply, the same as I used to pay for a one-month supply.

10

One thing I love about where I get mine is that you can get up to year’s worth at once. They offer EXTRA discounts most of the time if you get more than five or six at a time. It makes a lot more sense, especially as it’s a good idea to keep a second pack on hand in case you screw up taking them or something and have to start over…hell, the package instructions say to keep a second package around! How are you supposed to do that if you’re only “allowed” one at a time???

11

I use the mail in pharmacy for my long term prescriptions. I get 3 months for one co pay and the meds are delivered to my door. The only time I end up at the pharmacy is when I need antibiotics or something immediate and short term.

I will also suggest asking for samples. When I was young and uninsured samples saved me a lot of money and my doctor was the one who handed me the sample packs and told me to remind him when I needed more.

You can fight the insurance company. I don’t know which insurance you have and how your state laws differ from mine but there should be some channel of appeals you can take. It will probably be a lot of calling and letter writing but if you have all your documentation you should eventually prevail.

Have you talked to your doctor about seasonale? or even Depo? I’ve heard depo can mean no periods at all while you take it!

Good luck.

12

I, too, am going to suggest that you check to see if your plan offers a mail order pharmacy. With our mail order pharmacy, you get a three month supply of your ongoing prescriptions, for two co-pays. Walk in pharmacy, you can only get one month at a time, so you have to go every month.

My guess as to why they do this: they pay the mail order company much less than they pay the individual pharmacies, so they try to encourage you to use mail order by making it harder to use your hometown pharmacy.

13

Unless you’re planning to change insurance companies, the best course of action is to use the insurance company’s appeals process.

Have your doctor’s office contact the provider services department of your insurance company. Have them explain the situation, and what do they have to do to get this covered? It may have to go to the clinical-services department, who will review medical records and previous claims.

The problem with insurance company customer-service reps is that they’re basically allowed to tell you what you already know. They have little, if any, authority to make an exception and cover something. A clinical-services person, OTOH, can make that exception.

Robin

14

Wow. That totally sucks :frowning:

15

Try billing the insurance co for your time off work.

16

Argh - had a long reply typed out and lost it.

Aeryn - another thing to look forward to. I want to have our first baby in a birthing center or a home birth with a midwife, and I know that’ll be an issue with the insurance company. Yay!:slight_smile:

nyctea - I actually take chryselle, which is the generic of lo/ovral. I think it’s because I need a lower dose of estrogen due to my endo - that’s how my gyno explained it.

Thanks for the suggestions. I’m hoping not to be with this company much longer. But in the meantime, I do plan on complaining to them, and if I have to, I’ll go to the VA state insurance board. It really just ticks me off to no end. And what’s even worse is that my old boss said we should be grateful that they’d pay for any BC at all because our last insurance company refused to pay for ANY of it! It was quite annoying:).

Ava