Friday, September 29, 2006
Digging deeper into the shortcomings of my new insurance.....
Dan's new health insurance has limitations beyond what I expected, at least in the realm of prescription med coverage. While I can go see any doctor on their list without a referral (which is a great relief considering how many specialists I need), when it comes to medications, they basically won't pay for anything that's not mainstream or dirt cheap. If only I could comply and be either completely healthy or not have anything but mainstream ailments.
I knew I might be in for some trouble when I acquired a short list of their formulary. I didn't expect everything I take to be on there as I have a grand total of 19 medications; 12 of them are taken on a regular basis and the other 7 on an as needed basis. And I figured they probably wouldn't cover the newest meds. But it was sort of a shock to not see several of the medications I've been taking for three or four years. I thought maybe these would be on the full length formulary. I attempted a few times to get a look at it on the website I was directed to, but I kept losing my internet connection before the page would load, so I ended up calling the insurance company instead.
I guess it would be best described as a wake up call. First, I asked them to go over their definition of maintenance medication. My previous insurance allowed me to fill anything I'd been prescribed at least a year at their mail order facility. I would order three months at a time and only have to come up with a co-pay for two of those months. Eight of my medications were handled this way. The new insurance unfortunately will only allow "life saving" long term meds to be filled at 90 day intervals, and you must pay the co-pay for each month all at once. Right now, only my Metformin, a diabetes med, qualifies. Thyroid medications are considered maintenance, but neither drug I take is on the formulary. They only cover Synthroid, which I tried years ago with no success. I take Armour thyroid and Cytomel. I was informed the only way these would be covered would be if my doctor sent them a letter of medical necessity stating that the drug on the formulary was not suitable for me and requesting that the insurance company make an exception in my case. If the meds are approved, I will be charged what is called a "third tier" co-pay, which is $15 higher per month than the name brand co-pay.
It got even more complicated when it came to Seasonale, an oral contraceptive I am using as estrogen therapy to treat adenomyosis. Their formulary says that they will only cover the generic equivalent. I said fine and had my gynecologist send the pharmacy a new script. But then I am told that because Dan's employer is in South Dakota, they don't cover oral contraceptives AT ALL. How barbaric is that? So now I need to get the doc to write a letter requesting an exception because I am treating a medical condition and am not taking the pills for birth control. If the insurance company doesn't approve an exception, I'll have to cough up full price for the generic. Luckily, the Premarin I have to take for extreme dryness associated with Sjogren's is covered, so at least I won't have to jump through any hoops for that.
Then there is Nexium, which is not covered at all. I have to take a generic form of either Prevacid or Prilosec, I forget which. And even the generic is only covered for 90 days. In order to get the insurance to pay for more than 90 days, I have to provide a letter from a gastroentereologist stating that I have a chronic medical condition on their list. I do have some of the digestive problems they list, so I qualify, but that makes doctor number three I have to get a letter from.
The meds I am taking for Sjogren's syndrome are less complicated. They do fully cover the generic form of Plaquenil, yay, but I will have to get it filled every month as it is not a maintenance med. They do not cover Evoxac at all, and in fact, the insurance rep had never heard of it. So I have to switch to Salagen, an older version of the med that is less effective with more side effects. Rats. As for the Mobic, I am told that there is a generic coming out, so I will have to switch once that becomes available. They will continue to cover Mobic ONLY if you have rheumatoid arthritis. I pointed out the Sjogren's syndrome is very closely related to RA but was told it doesn't count.
I am totally amazed that my Restasis is covered. It's new and trendy and very expensive. But there really is no other prescription med like it, so I guess the insurance compnay's hands are tied. I'm sure that as soon as a generic is on the market, I'll have to switch to it.
The Lunesta is a real thorn in my side. Not covered at all. The insurance company expects me to switch to Ambien, and not the controlled release version either, the old one. Problem is, Ambien is not designed for long term use, and Lunesta is, so how is a person with a permanent sleep disorder supposed handle this? You guess it: ANOTHER letter! Actually this makes no sense at all to me as Ambien actually costs about the same as Lunesta, so I don't understand why the insurance company is favoring it. I guess their members aren't allowed to have long-term sleep disorders.
Luckily, five of the meds I take on an as needed basis are covered: Erythromycin, Triamcinolone, Diazapam, Baclofen and Mometasone. The other two as needed meds, Skelaxin and Miralax, aren't listed, but I'll deal with those later if I have to. Right now, I'm just going to focus on what I need to function on a daily basis.
I did see my primary care doc yesterday as she is one of only two of my current docs covered by the new insurance. She is going to write the letters for Armour thyroid, Cytomel and Lunesta. My other covered doc, the rheumatologist, I can't get in to see until November, but I've got enough Sjogren's meds stockpiled to allow me to get by. I'll have him switch me to Salagen if he thinks it best and switch to the generic Mobic. That leaves me with two docs that are no longer covered, the gynecologist and the gastroenerologist, that I need to contact to ask for letters.
Even if I make all the required substitutions and/or obtain exceptions, what all this means in terms of dollars and cents is that I can pretty much expect my monthly med expenses to be double what they were under my old insurance. This really sucks as I had budgeted for much less. I'm hoping that I can make up the difference somewhere, like maybe by having cheaper car insurance or paying less for groceries or something. And those things won't be possible until after I move. Grumble.
One upside might be that I am eligible for Medicare next year. I can probably get cheaper meds for at least six months out of the year. Unfortunately, they have a pretty low ceiling for coverage, and most Medicare recipients max out on their prescription co-pays long before the end of the year, a phenomenon called the donut hole. But it would still be better than Dan's insurance alone.
How I miss the good old days, when I was so healthy that all I needed was a birth control pill and a daily multi-vitamin! I remember when the co-pay for generic birth control pills was only $3! How the hell did I get so high maintenance? And how the hell can people with no insurance even get by? This is insane.
Part of me wants to go on strike, to refuse to take any more meds. But I suppose becoming bedridden wouldn't do anyone any favors. Sigh.
Maybe I should start buying lottery tickets.
I knew I might be in for some trouble when I acquired a short list of their formulary. I didn't expect everything I take to be on there as I have a grand total of 19 medications; 12 of them are taken on a regular basis and the other 7 on an as needed basis. And I figured they probably wouldn't cover the newest meds. But it was sort of a shock to not see several of the medications I've been taking for three or four years. I thought maybe these would be on the full length formulary. I attempted a few times to get a look at it on the website I was directed to, but I kept losing my internet connection before the page would load, so I ended up calling the insurance company instead.
I guess it would be best described as a wake up call. First, I asked them to go over their definition of maintenance medication. My previous insurance allowed me to fill anything I'd been prescribed at least a year at their mail order facility. I would order three months at a time and only have to come up with a co-pay for two of those months. Eight of my medications were handled this way. The new insurance unfortunately will only allow "life saving" long term meds to be filled at 90 day intervals, and you must pay the co-pay for each month all at once. Right now, only my Metformin, a diabetes med, qualifies. Thyroid medications are considered maintenance, but neither drug I take is on the formulary. They only cover Synthroid, which I tried years ago with no success. I take Armour thyroid and Cytomel. I was informed the only way these would be covered would be if my doctor sent them a letter of medical necessity stating that the drug on the formulary was not suitable for me and requesting that the insurance company make an exception in my case. If the meds are approved, I will be charged what is called a "third tier" co-pay, which is $15 higher per month than the name brand co-pay.
It got even more complicated when it came to Seasonale, an oral contraceptive I am using as estrogen therapy to treat adenomyosis. Their formulary says that they will only cover the generic equivalent. I said fine and had my gynecologist send the pharmacy a new script. But then I am told that because Dan's employer is in South Dakota, they don't cover oral contraceptives AT ALL. How barbaric is that? So now I need to get the doc to write a letter requesting an exception because I am treating a medical condition and am not taking the pills for birth control. If the insurance company doesn't approve an exception, I'll have to cough up full price for the generic. Luckily, the Premarin I have to take for extreme dryness associated with Sjogren's is covered, so at least I won't have to jump through any hoops for that.
Then there is Nexium, which is not covered at all. I have to take a generic form of either Prevacid or Prilosec, I forget which. And even the generic is only covered for 90 days. In order to get the insurance to pay for more than 90 days, I have to provide a letter from a gastroentereologist stating that I have a chronic medical condition on their list. I do have some of the digestive problems they list, so I qualify, but that makes doctor number three I have to get a letter from.
The meds I am taking for Sjogren's syndrome are less complicated. They do fully cover the generic form of Plaquenil, yay, but I will have to get it filled every month as it is not a maintenance med. They do not cover Evoxac at all, and in fact, the insurance rep had never heard of it. So I have to switch to Salagen, an older version of the med that is less effective with more side effects. Rats. As for the Mobic, I am told that there is a generic coming out, so I will have to switch once that becomes available. They will continue to cover Mobic ONLY if you have rheumatoid arthritis. I pointed out the Sjogren's syndrome is very closely related to RA but was told it doesn't count.
I am totally amazed that my Restasis is covered. It's new and trendy and very expensive. But there really is no other prescription med like it, so I guess the insurance compnay's hands are tied. I'm sure that as soon as a generic is on the market, I'll have to switch to it.
The Lunesta is a real thorn in my side. Not covered at all. The insurance company expects me to switch to Ambien, and not the controlled release version either, the old one. Problem is, Ambien is not designed for long term use, and Lunesta is, so how is a person with a permanent sleep disorder supposed handle this? You guess it: ANOTHER letter! Actually this makes no sense at all to me as Ambien actually costs about the same as Lunesta, so I don't understand why the insurance company is favoring it. I guess their members aren't allowed to have long-term sleep disorders.
Luckily, five of the meds I take on an as needed basis are covered: Erythromycin, Triamcinolone, Diazapam, Baclofen and Mometasone. The other two as needed meds, Skelaxin and Miralax, aren't listed, but I'll deal with those later if I have to. Right now, I'm just going to focus on what I need to function on a daily basis.
I did see my primary care doc yesterday as she is one of only two of my current docs covered by the new insurance. She is going to write the letters for Armour thyroid, Cytomel and Lunesta. My other covered doc, the rheumatologist, I can't get in to see until November, but I've got enough Sjogren's meds stockpiled to allow me to get by. I'll have him switch me to Salagen if he thinks it best and switch to the generic Mobic. That leaves me with two docs that are no longer covered, the gynecologist and the gastroenerologist, that I need to contact to ask for letters.
Even if I make all the required substitutions and/or obtain exceptions, what all this means in terms of dollars and cents is that I can pretty much expect my monthly med expenses to be double what they were under my old insurance. This really sucks as I had budgeted for much less. I'm hoping that I can make up the difference somewhere, like maybe by having cheaper car insurance or paying less for groceries or something. And those things won't be possible until after I move. Grumble.
One upside might be that I am eligible for Medicare next year. I can probably get cheaper meds for at least six months out of the year. Unfortunately, they have a pretty low ceiling for coverage, and most Medicare recipients max out on their prescription co-pays long before the end of the year, a phenomenon called the donut hole. But it would still be better than Dan's insurance alone.
How I miss the good old days, when I was so healthy that all I needed was a birth control pill and a daily multi-vitamin! I remember when the co-pay for generic birth control pills was only $3! How the hell did I get so high maintenance? And how the hell can people with no insurance even get by? This is insane.
Part of me wants to go on strike, to refuse to take any more meds. But I suppose becoming bedridden wouldn't do anyone any favors. Sigh.
Maybe I should start buying lottery tickets.
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