Monday, April 02, 2012

A very bitter pill indeed.... 

I am extremely ticked off at the insurance company because I wasted four months trying to get a generic medication covered at the proper level. Their co-pays are based on Tier 1, which are "approved" generics; Tier 2, which are "non-approved" generics; and Tier 3, name brands. They are charging me the brand name rate for Pilocarpine, which is the generic form of Salagen and a very old medication; all my previous insurance companies covered it at the cheapest rate.

Pilocarpine is what people with Sjogren's syndrome take to help their bodies produce moisture; the only other medications of this type that exist are Salagen and one that is even more expensive called Evoxac. A brand-name co-pay doesn't sound like any big deal until you factor in that I am on a Medicare Advantage plan subject to the doughnut hole. Sometime this summer, my co-pays will disappear, and I will have to pay full price for this medication, which will cost me approximately one-third of my SSDI benefit. And that's not counting my dozen other medications I have to take regularly!

I called the insurance company in January, and they said my rheumatologist had to contact them, which she did. Their response was a denial, but it was only over the phone with no explanation. They are supposed to given me a written response, and getting none, I called them in February, and they said I had to write a letter, which I did. Again, no response; I called in March, and they said they didn't get the letter but then changed their story and said the rheuamatologist had to contact them again, which she did.

Today, I got two letters from the same address and the same date with a denial for two different reasons and two different methods to resolve it. I called again and spent an HOUR getting transferred back and forth. Finally, someone supposedly in authority gave an "official" response; that Pilocarpine is not eligible for a generic co-pay because nothing cheaper is available. WHAT? Isn't that why we are supposed to get the lower co-pay in the first place? I told the woman this made no sense, and then she blamed the drug company, babbling incoherently about pharmaceutical firms hiring Antonio Bandaras to advertise medication. I told her that Antonio Bandaras has never done an ad for something that gives people the ability to spit. Then she said that chemotherapy-type medication is usually given the brand-name rate even if it is generic. I lost it and began yelling that I'm not on chemo. She yelled back that it doesn't matter because I can't do anything about it. I hung up on her.

They could have saved me four months of grief by putting a clause in their evidence of coverage booklet that they can ignore their own tier system any time they wish. I am out an extra $650 this year. I guess in October, when open enrollment for Medicare starts, I will be shopping for a new insurance company.

The only upside to this whole thing is that I will hit catastrophic coverage this year. Last year, I came within $200 of qualifying for reduced co-pays after shelling out about $4500 out of pocket for medication. This year, I will have about, oh, three weeks of reduced co-pays. Hooray for me.

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