insurance companies are crazy

[earendel]

Yesterday elwing had a bone marrow biopsy. Not because there was anything wrong; on the contrary, ever since she started the drug Thalomid for her myelodysplasia her symptoms have virtually disappeared. However, after being on this drug for 5 years, this year our insurance company declined to pay the $5,000 for the drug because her disease "isn't on the list of diseases for which" the drug is recommended. Her oncologist appealed the decision, and provided five years' worth of blood tests and such to show that it was extremely effective. The appeal was denied. The company said that there were other drugs that can be prescribed. So the doctor had to go back to square 1 and do a bone marrow biopsy for a "baseline". elwing will be off any medications for the next 12 weeks and will have to be monitored to see if the dysplasia comes back (low iron, etc.). What makes me crazy is that the insurance company is willing to pay thousands of dollars for the biopsy and follow-up doctor visits, blood tests, etc., rather than paying for the Thalomid that has already been shown to work. Seems rather penny-wise, pound-foolish if you ask me.

[ghostjmf]

This is crazy. I wish you could just pay for the med.

My insurance is meddling w/ one of my meds too. The CNP says they are doing that w/ everybody in the practise that's on it, that they even wrote practise a direct letter about it & I'll just have to accept sub. Since drug is in long public use w/ no new bad news about it, I'm sure reason is just expense.

[triviawayne]

How could this happen, we have Obamacare in this country--Moron-in-Chief fixed everything...

[Bob78164]

How could this happen, we have Obamacare in this country--Moron-in-Chief fixed everything...

I believe earendel works for, and gets his health insurance through, the federal government, so the Affordable Care Act didn't affect his coverage.

But do you really think things would have been better on that front before it passed? --Bob

[Catfish]

Crazy like the devil. My husband went through something similar regarding a test---nothing as serious as Elwing's drug treatment. His doctor wanted an imaging study but some desk jockey MD at the certification company used by his self-insured employer declined, declined, declined after much back and forth with the doctor. After a while it just seemed that the desk jockey was sticking to his guns just for the hell of it no matter what the doctor said. But like, who the hell is he?

I wish Elwing well during her uncalled-for time off the drug and her unnecessary biopsy and its aftermath.

Grrrr.

Love

[earendel]

How could this happen, we have Obamacare in this country--Moron-in-Chief fixed everything...

Obamacare isn't the issue - it's not that "I like my health insurance so I can keep it". It's a change in the insurance company's policy on what drugs they cover. It's my understanding that this happens all the time, for one reason or another (probably cost/benefit ratio or liability concerns). I just find it infuriating that the company would stop covering a drug that has a proven track record of treating my wife's disease and require her to go through several bone marrow biopsies, blood tests and such, as well as risking her having to go back to having biweekly transfusions, all covered, and all more expensive than the cost of the drug itself.

[ghostjmf]

Just for the record, I am not on Affordable Care either. My insurance has changed, but the drug provider is the same one, & my insurance is from a branch of the former insurerer.

Kicking you off of expensive drugs & treatments is a way insurers get to keep your money. They don't care about the health of the patient. They're in the business for the money. In my case there are substitutes, the main drawback of which seems to be "effects are shorter-lasting". We might be talking more pills, in smaller doses, a day, we might be talking some other-than-pill delivery system, as drug in question reportedly gets taken apart by digestive track, so you can take a lower dose if you bypass it.

Also, more importantly, in my case its very important to me, but not life-or-death. That elwing's case really is life-or-death doesn't seem to phase the insurers, does it.

I'm waiting to see if they plan to mess with drugs I'm on that are eventual life-or-death. With stuff like blindness & amputations of extremities en route without them (diabetes meds). They're generic, though, so I don't know how they could find a sub that costs even less.

[ghostjmf]

Something that blew me completely away when my Mom was going back & forth from hospital to "recuperative home" (because hospital had discharged her too soon) is that the recuperative/rest/whatever home required she go off all her meds. For 3 or 4 days, sometimes. While they checked to see (A) if they stocked the same meds & could therefore legally sell them to her at some rate way above what she'd already paid & (B) if any of her meds they didn't stock, so couldn't sell her, weren't really some kind of street drug she was trying to sneak in. Not a lot of old Jewish ladies in their 80s are sneaking in street drugs, but the homes always tell people that because some of their patients are substance-abusers in recovery, they have to assume that all their patients might be. They never seemed to give a hoot that knocking an old woman on various meds for diabetes & blood clots off those meds could do serious damage while they were running lab tests on them. For which I'm sure they charged the insurance.

They also flat-out lied. "Send your patient here, we have the wound vac she needs", meant "we can get a wound-vac. It could take us a week. Sorry if you get infected & die while waiting, its the luck of the draw".