By Brenda McFarlane / OB Rag
It’s happened again. I have been denied coverage for Modafinil yet again, this time by the exact same company who has already approved it.
I’ve been on a prescription medication that treats my Ideopathic Hypersomnia for several years now. It’s an extremely expensive drug, even the generic form can be more than a $1000 a month. I have been diagnosed by a esteemed sleep doctor in San Diego and he confirms that the drug is both medically necessary and that no effective (and non-narcotic) substitute exists.
Without the drug I suffer from sometimes overwhelming sleepiness. Without it I get a band of sleep deprived headaches, driving may be either impossible or require pulling over to take naps, even after 5 minutes on the road. I grew up with this condition – undiagnosed – and lost years of my life to sleepiness. Smoking cigarettes or eating sugar were the two things I could rely on to help stay awake especially to drive.
I am writing this as I wait on hold for the next patient care advocate with Express Scripts, I am at 43 minutes.
I have grown to believe that this denial is purposeful bureaucratic complexity nurtured to thwart as many people as possible from getting expensive prescribed drugs. I believe this ineptitude within the Health Insurance System, the Pharmacies and the Doctor’s office is actually orchestrated on purpose by Insurance companies to save them money.
Creating a system engineered to make it difficult for the ordinary person to get their prescription paid for is as simple as bringing together enough of the following components; employees without initiative, lack of clear information, information overload, confusion, poor communication lines, information hidden underneath layers of other information, disconcerting medical terms, and allowing the accidental and incorrect information dispersal. .
I am presently at 58 minutes in my time-consuming run around to get the information I need to get my medication. I can’t imagine how I would manage to fight through this labrynthian system if I had a job, had difficulty hearing, had an impairment or, God forbid, was sick or in pain!
It is hard to imagine the CEO and high level directors are unaware that their system keeps their insured from receiving their covered medication.
What caused my present inability to get my prescription filled is that I changed my health insurance from my husband’s Anthem Blue Cross coverage to a different Anthem Blue Cross program. This seems to have given Anthem Blue Cross an excuse to once again deny my medically necessary prescription despite that the drug is listed in a formularly published on the web dated October 2013 (which I checked before signing up) and they have already put me through the very same rigamoral 2 years ago, meaning that they already have everything they need to prove that there is not another form of drug that can help me and that I have the exact diagnosis that this drug is made to treat.
Still, the system has found a way to deny coverage and I have no recourse to go through a series of hoops. My phone just ran at of battery power at 1 hour 13 minutes so I changed phones…
On Monday, The first hoop was my pharmacist at Rite Aid, a cold and disinterested young lady if ever I met one. She was put out when I told her she needed to call my insurance plan after she told me my medication wasn’t covered. She informed me it would “take a long time to get through”. Yeah, well, sorry to make you do your job was what I thought but I kept it to myself.
I returned in an hour and she said that my drug is not on their formulary and it is a closed formulary. I waited for any further information, she had none. Getting more information from her was like ringing water of a dry towel. She did manage told me I could pay for the medication myself but it was expensive (did I mention it cost more than a 1000 a month?).
Next I called and emailed my Doctor, they are notoriously difficult to reach, only in the office from Monday to Thursday, 1 hour lunches and they don’t answer the phone. Left a message.
Called the number on the denial note the pharmacist gave me. Went around and around, three different operators put me through to themselves. That took about 45 minutes. All the information I got was I needed to get my Doctor to call them.
Doctor’s office didn’t call me back or email me any response on Monday, No drug for me, sleepy.
On Tuesday afternoon, I finally heard from my Doctor’s Assistant, she told me she was waiting on-line with the same people I called the day before. She’d been waiting more than an hour. She wanted to know if I had another number to call. I didn’t. Again no modafinil, sleepy. Went to bed at 10:00 pm
Wednesday: Awake at 8, still sleepy. At 8:30 on the telephone with Express Scripts. It is now 10:20am and I’ve talked to Sierra and am waiting to talk to a Supervisor.
Sierra told me that the Doctor’s Office called and initiated a Coverage Review.
The Coverage Review went to the Medical Director. It will take 72 hours for a response.
The response will go directly to my Doctor’s office, not to me. I will be sent a letter.
I’ve learned that I can’t rely on my Doctor to contact me and they are closed on Fridays. So I can either wait for the letter or try to get my friendly neighborhood pharmacy to call for me to see if I have been approved.
If I don’t get approved, well then I can appeal.
Talked with Supervisor after about a 40 minute wait. The conclusion to this is that I will continue to be denied a medically necessary drug because of a inexcusably complex and inefficient bureaucracy, effectively saving the insurance company hundreds of dollars.
So, do they have any reason to improve their system if it saves money? I don’t think so.