Monday, February 20, 2017

The Successful Patient: What's it like to have a Chronic Illness?

We've all had the experience of acute illness -- a cold, the flu, food poisoning, or infection. These illnesses are short lived.  While there is no cure for the common cold, we know that our bodies have effective methods for stopping the virus in its tracks. It usually takes about a week, but then we're fine.

A chronic illness is an illness that will not go away. It has no cure. Modern medicine often hasn't a clue at what the cause is. In fact, in many chronic illnesses, the body and its immune system are the culprits. These are the autoimmune diseases and I've written about autoimmunity before. Treatments usually involve managing symptoms, or trying to stop a disease process to make the disease inactive (remission). But even if the chronic disease is inactive, it has not been cured and will return if treatment is stopped.

What's it like to have a chronic illness? In my personal experience, I've found that most people haven't a clue what it's like and so they make wrong assumptions, say inappropriate things, and ask irrelevant questions. Using myself as an example, I'd like to provide a glimpse into the life of someone with a chronic illness.

Daily Life

I wake in the morning and my first thoughts focus on how I'm feeling. When I stand, am I stiff? Do I have pain? Do I have nausea? Are any joints swollen? How's my balance?  I have a routine now that I follow to get into the day that includes some stretching to help alleviate the stiffness, moisturizing my mouth and eyes against the dryness, and taking my scheduled medications. It's important that I eat well during the day, i.e. no junk, no sugar, and follow my diet to insure that it remains quiet. It's also important that I eat by certain times due to my medication schedule.  I have a medication that must be taken on an empty stomach twice a day. The morning is no problem, but the evening can be. In the morning, I also have a schedule for the different meds before and after breakfast. By taking my medications correctly, I increase my success at managing symptoms and being able to go through my day well.

What happens when one of the diseases flares up? Well, I just had that happen with my Interstitial Lung Disease (ILD) which was triggered by a new medication. When the ILD flares, I can be quite ill and it's best if I stay home and take care of myself. When the psoriatic arthritis flares, I'm in extreme pain from the affected joints. Sometimes pain meds will stop that pain or at least dull it, but sometimes they have no effect. It's really hard to walk when the joints in my feet are inflamed. It's been years since I've had a flare of the Sjogren's, and I'm thankful for that. It can affect my inner ear and balance, my swallowing, and can give me a mighty sinus headache as well as swell my salivary glands. Not fun. People see the swollen glands but otherwise, the only chronic illness I have that people actually see is when my psoriasis flares which is a prominent, red, pustular skin rash on my scalp, along the hair line, on my arms, back, legs, palms and feet. I've written about dealing with the fatigue that goes with autoimmune diseases here and here.

So I have chronic illnesses but rarely are visibly sick. I've heard comments such as "You don't look sick" or "You're faking it -- you look fine." Doctors and nurses have told me that they can tell when someone is faking it in a variety of ways, especially in the person's behavior. The average person doesn't have that expertise. What I usually do in that situation is to explain the disease that is flaring, why I look "fine," and why I'm not fine. Most people with chronic illnesses are not visibly sick. Please don't assume that if someone doesn't look sick that they aren't.

At work, I must pace myself in order to conserve energy. I take with me whatever I need to help me deal with symptoms that could interfere with my job. This includes nasal spray, eye drops, throat lozenges, my inhaler, and OTC meds that help me digest food. I do not talk about my chronic illnesses at work, unless I'm out sick with one. Very few of my co-workers know about them. And as long as I take care of myself, there's no reason to bring them up. As long as I take care of myself, I'm rarely out sick.



Doctors and Medications

I have a medical team not just my primary physician. In order to stay ahead of my diseases, I see my doctors usually every 3-4 months when my diseases are active, and every 6 months when they are not. Most of my medications are taken orally, but I do take two that are administered by infusion in a doctor's office, and one by intramuscular injection that I do myself.  My infusion appointments occur every 8 weeks and every 12 weeks.  If I'm lucky in scheduling, they are both due at the same time, but usually they're not.

It's important to be committed to keeping medical appointments and to take medications according to instructions. Deviating from this can cause diseases to flare or other problems.  I know that I do as well as I do because I keep my medical appointments and take my meds.

In an effort to have some control over my body and health, I also have tried alternative therapies. Often with my doctors' encouragement. I've tried Reiki, massage therapy, Tai Chi, Falun gong, meditation, and different kinds of physical exercise. I've also attended support groups for people with the same diseases I have where discussion topics have included alternative therapies, diet, holistic approaches, and chiropractic medicine. I've found Reiki, Falun gong, meditation, and physical exercise the most helpful to me.  I've also developed my own diet of safe food that doesn't cause a flares. 

Medical Insurance Companies

Medical insurance is a business, and people who work for insurance companies are tasked with saving the company money, not paying it out. So medical insurance companies do not like people with chronic illnesses because they submit the most claims and cost the insurance company the most money. So insurance companies will play a passive-aggressive game of stalling and using bureaucratic language that confuses rather than clarifies. Medical insurance companies are not your friend, especially if you have a chronic illness. Don't believe any of the niceties they include in their correspondence or brochures, their advertising or through customer service. When they claim to be looking out for the patient and the patient's health, that means that they are looking out for themselves and their bottom line, not the patient. Everything they do is to save money for them.



In my experience both pre- and post-ACA, dealing with insurance companies has exacerbated my symptoms and hurt my mental health. It's important to stay as positive as possible when you have a chronic illness, and there's nothing in the way insurance companies treat their customers that is helpful to staying positive. They claim that they are not practicing medicine, and yet they also claim in their written materials and on their website to be actively determining if a treatment or medication will be effective for a patient, even after the patient's licensed physician has already made that determination. It's all about money, folks. It has nothing to do with the welfare of the patient, but how much the patient will cost them.

For someone with a chronic illness, it can be almost a fulltime job to deal with medical insurance companies. On top of everything else, of course. Our current system definitely needs reform. The ACA was a solid beginning, but what the Republicans are proposing now would set patients and doctors back 20 years to a time when medical insurance companies had complete control and power, especially over whom they will insure and how much they'll charge.

Chronic illness is expensive. If I did not have medical insurance, I would be dead because I could not pay for all the medications, the hospitalizations, the clinic and doctor visits out of pocket.  No one can.

Depression

Depression is a side effect of chronic illness, and can be serious.  It is unbelievably difficult to live with pain, with extreme symptoms, day in and day out. More often than not, doctors run out of treatment options or insurance companies refuse to cover the treatments doctors have prescribed. The anger and frustration a patient feels about all these things needs to be expressed not internalized. Anxiety about the future is also a common occurrence with the chronically ill.

Depression has its own set of symptoms that need to be treated. I took an anti-depressant for years for anxiety as well as went through talk therapy. I'm no longer doing either. But that doesn't mean that the depression and anxiety cannot recur. People who live with chronic illness, whether one or multiple, are incredibly strong but they still need emotional and psychological support from family and friends when they're not feeling well.

Finally

No one wants to be sick. I know of no one who enjoys having a chronic illness. And the thing is, chronic illness occurs whether or not a patient has been healthy all her life, takes care of herself, or not. The patient has no control over whether or not the chronic illness hits her. A great deal of medical research is going on right now looking at the genetic component of chronic illness, figuring out each disease's process within the body in order to develop new treatments and maybe even to find a cure. Until then, I and all the millions of people with chronic illness in this country power on, doing everything we can to take care of ourselves, and ignoring the people who are ignorant, insensitive, and boorish toward us.


May you never, ever have to deal with a chronic illness.


 

Friday, February 10, 2017

Open Letter to Donald Trump: Checks and Balances

Welcome to American Democracy! Not a Kingdom, not a Dictatorship, and not a Communist Police State. A democratic Republic. Our American Democratic Republic has been in existence, functioning well, for much, much longer than anyone alive today. Thanks to strong and real leadership, the Civil War did not destroy the country but showed us where we needed to improve to honor those who fell during that war and ushered in years of beneficial change. But how could the men who wrote our governing documents have known how to create our democratic Republic. Many were motivated to create a government that would insure freedom for its citizens, rule of law, equality under the law, and a representative government -- not the monarchy that they had suffered under.

Most adult Americans today studied how the Founders feared any one part of government gaining too much power, feared a monarchy in which the people had no say, and were determined to insure freedoms that we take for granted now. Freedoms that they did not necessarily have. Freedoms that anyone living in a dictatorship can tell you they want...desperately.

To look at a business analogy: there are some companies that are run as a dictatorship with financial and operational secrecy, in which employees must do as they're told whether or not they agree, are not encouraged to speak up in dissent, are not encouraged to offer new ideas, the management style is by fear, negativity and the suppression of innovation, and there are no checks on the power at the top. Whatever the dictator says, goes.

Then there are companies that have Boards of Directors, shareholders who share in the risk of ownership, that operate with financial and operational transparency, that encourage innovation and their employees to speak up, share new ideas, and are open and positive with a management style that supports employees and productivity, and there are checks on the power at the top because power's not consolidated as in a dictatorship.

The American Constitution written by the Founders, voted on by them and those they represented, provided instructions on what the American government would be. Amendments have been added over the years after being voted on by Congress and the States, and the first 10 Amendments, the Bill of Rights, outline the freedoms and rights of the American people guaranteed by their democratic government. Described within the Constitution is the structure of the American government, its processes that will best achieve results in a government by the people, for the people and of the people.

You vowed, Trump, when you took your Oath of Office to uphold and defend the Constitution. It is your duty now, part of your job -- maybe the most important part -- to protect and insure our democracy, democratic processes, and freedoms, to enforce and uphold the law. When you took your Oath, you were also accepting the Constitution as our governing document, and accepting the laws contained within it.


It is the law of the United States that our federal government has three branches: the Executive, the Legislative, and the Judiciary. The Executive and Legislative branches work together to write and pass laws, and uphold the rule of law in this country. The Judiciary's job is to insure that those laws do not violate the Constitution. In addition, the Legislative branch also checks the actions of the Executive branch. The three branches balance each other out as well as work as checks on each other. That's their job. They serve at the pleasure (and the vote) of the American people whom they represent, except for the Judiciary. This branch is not political, not elected, and must be impartial.

So the President, the top person in the Executive branch, serves the American people -- ALL of them, not only the people who voted for him or her. A President ignores his bosses at his peril.

The Capitol where Congress works
 Let's take a recent example from your life: the immigration ban on seven specific countries that are Muslim majority countries, but this ban does not include all Muslim majority countries since it leaves out Egypt, Saudi Arabia, and Pakistan for example. You signed an executive order implementing this immigration ban to last for 90 days for some people, 120 days for others. You did not run this order past any of the government agencies who'd be charged with enforcing the ban or who are responsible for determining the legalities of it or how it might not be legal. Your stated objective was to protect America from terrorists, a good and valid objective.  Too bad it was so poorly done, focusing on countries from which terrorists have not attacked us (and for which the previous President had already put into place vetting orders that would protect, and has protected, the country). One thing the President cannot do is take such a serious action just for show, i.e. to say that he's kept a promise, for example.

The "checks" kicked in immediately, beginning with regular Americans protesting this order at American airports. We have Freedom of the Press guaranteed by the First Amendment, and they provide an important check to government abuse of power. The Press was all over this order immediately. Finally, the Judiciary, responding to legal requests in different forms, put the kibash on your executive order, checking your power as it should, and has been reviewing appeals ever since. Will it make it to the Supreme Court? Probably. We have an 8-member Supreme Court right now -- it should have 9 members and would have had if your political party had not stonewalled your predecessor's nominee -- which means that it could uphold the Appeals Court ruling because it might not have a majority either way.


U. S. Supreme Court
 Welcome to American Democracy!  When you campaigned for president, one of the first things you needed to do was educate yourself thoroughly about the system of checks and balances, what the role of the President is, how to work with the Legislative branch (I suspect you're going to butt heads with them in the future, too), and especially the role of the impartial Judiciary. You may be president, but the presidency is not you, Trump. It is your job to serve the American people, all of them, and so far, you have really failed miserably and it's nobody's fault but your own. You are not the government, you are not the boss anymore. You are the employee of 311 million or so people.  We expect you to uphold the rule of law, stop obsessing over tiny things, and focus on the job.

The American democratic republic is not run like a dictatorship business. You want results? I repeat: do you really want results? Then you need to master the democratic processes not ignore them. When you ignore them, when you dictate instead of propose, when you dictate instead of seek to build consensus, the Legislative branch is going to be all over you like white on rice.  Because they have their jobs to do too, and they have an election coming up in 2018 and need to pay special attention now to what their constituents want. And they took an Oath of Office to uphold, defend and protect the Constitution, too.

Checks and balances, Trump. It's not about you personally, and the faster you get that, the faster you'll be able to move on and get something done. Checks and balances. They are what make American democracy great, not you or any one person.




Wednesday, February 1, 2017

What Makes a Wonderful Neighbor?

While a stereotype of a "good neighbor" does exist, I've been thinking a lot lately about what makes a wonderful neighbor. As a kid, I grew up in a neighborhood where everyone watched out for each other, and it was perfectly safe for kids to play outdoors on their own anywhere. I found out years later at my father's wake that one neighbor had kept an eye on me when I played outdoors by myself, and had commented to me that she had especially enjoyed my singing. I didn't see her, and she hadn't wanted me to see her. Back then, the adults wanted their children to feel safe and secure playing outdoors on their own, exploring their immediate world, and walking to and from school. The adults wanted to feel safe and secure as well. Doors weren't locked at night until I was in middle school, and I never had a key to any of our house's doors.

As an adult now living in an urban apartment building, I think back fondly but realistically to my childhood and the neighbors we had. We knew them almost as well as we knew our cousins. And they knew us. There was communication among them, just as there was among the kids. We wanted the best for each other which didn't mean there weren't disagreements and occasional feuds. The adults taught us to be considerate and respectful of each other. Loud noise after bedtime? It'd only happen once because the police would arrive and issue a citation for disturbing the peace. If my parents weren't home when I arrived after school, I could go to any of the nearest neighbors to wait for them if I wanted (I usually just played outdoors). Neighbors picked up newspapers and mail for a family who'd gone on vacation and watched their house to make certain it remained secure. Were people just nicer to each other back then? I don't know, really, although it does seem so.

In the last few weeks, there's been a lot of loud noise after 10 p.m. in the building where I live. Someone actually posted a note in the front foyer about it, asking everyone in the building to be considerate and respect their neighbors who had to get up really early to go to work. I kept thinking, gosh, isn't it amazing that it even has to be said. To me being considerate and respectful is a given. But I guess there are people now who haven't been brought up to be considerate and respectful of others, to be aware of how their actions affect the people around them, or even that apartments are NOT soundproof no matter what they were told when they signed the lease. And people in apartment buildings no longer cultivate relationships with their neighbors, even if it's only to do each other favors like picking up mail when on vacation. (Mail? I still receive a lot of mail but I can imagine much younger people who don't.)

Canadian Prime Minister Justin Trudeau (Photo: The Canadian Press/Sean Kilpatrick)
And then there's the fact of countries being neighbors, as is true for Canada, the U.S., and Mexico. Americans have always been able to travel easily to Canada and Mexico, and Canadians and Mexicans have traveled to America. We share a continent. We should want each other to do well in the world and be supportive of each other, even if we have disagreements. And like any wonderful neighbors, we're considerate and respectful of each other. At least until recently.

American presidents have worked to cultivate a good relationship with our neighbors. In the past, there have been disagreements, even wars, but we have survived as neighbors. If we want them to be good neighbors to us, then we need to be good neighbors to them. It pains me deeply the way President Trump talks about Mexico, Mexicans, and tries to bully their President. I've noticed that he hasn't done the same with Canada which does make me wonder. If nothing else, Trump is an equal opportunity abuser. He is not a good neighbor. (Although I can hear him now: What da ya mean, I'm not a good neighbor? I'm the best, the greatest neighbor you've ever seen!)

Mexican Friends
Is his bullying bluster a result of his ignorance of how to conduct diplomacy and friendship among nations? Probably. But instead of being so loud, inconsiderate, and disrespectful, he'd earn more respect and friendship by being quiet, and seek out mentors who know what he doesn't so he can learn. But that's not Trump. He's not a good neighbor because he's unaware of how his actions affect other people (usually badly). He's only aware of his own desires to be the most powerful, most in control, and the best at everything that anyone has ever seen, and the problem is that he thinks he's already all of those things. I definitely would not want to be his neighbor. I'm sure he'd expect everyone else to do him favors while he never returned them. And he'd be loud far into the night, not caring the someone next door needed sleep in order to get up at 4 a.m. to go to a job.

Will Mexico and Canada decide that they no longer want to be wonderful neighbors to us? America and Americans would be stupid to lose our good neighbors. Especially when they can help protect us against terrorists. How? By the way they protect themselves against terrorists.

We share the same continent. We are all in this together.


Wednesday, January 25, 2017

Open Letter to Donald Trump: Fantasy vs. Reality

Dear Donald Trump:

You are the most amazing narcissist in the history of psychology! You make other narcissists look downright wimpy. The things you do and say that show just what an amazing narcissist you are -- just stunning. And today, I have so many things to write to you about, I didn't know where to begin.

So, let's start with those photos comparing Obama's 2009 inauguration crowd to yours. Snopes.com, the website that debunks memes, rumors, and anything else online and offline, does a very nice job of looking at the history of inauguration attendance, comparing Clinton, G.W. Bush, and Obama, as well as comparing yours and Obama's. Obama, without a doubt and a confirmed fact, set records of attendance at his inaugurations in 2009 and 2013, with 1.8 million and 1 million respectively. The photos that gained so much attention over the weekend on social media apparently were both taken at the same time in the proceedings, i.e. 45 minutes before the actual swearing in. Snopes.com shows these two photos also. Then there's the analysis of weather conditions and how they affected attendance and the use of public transportation in Washington, D.C. to the Capitol by 11 a.m. each of the inauguration days. What Snopes then reports:

"Some media reports cited organizers that pegged the expected crowd size for Trump's inauguration between 700,000 to 900,000 people — still a relatively large gathering."

A 900,000 total is nothing to sniff at, really, and beats both of Clinton's and G. W. Bush's inaugurations. I know that Obama kind of sticks in your craw, but your inauguration was not attended by anywhere near your 1.5 million mark. Your number is fantasy. The reality is less.

But you're the greatest narcissist ever, which means that what you believe, think, say is all about you not facts. Why bother with facts when what you say is so much better for you? 

KellyAnne Conway Photo: Mark Wilson/Getty Images
KellyAnne Conway, god bless her for standing up for you and Sean Spicer, and clarifying all the fantasy as "alternative facts." Got a howling laugh out of that one. So the "alternative facts" that make you look better than anyone else is what you believe. Screw facts. Who cares about facts when you're the most amazing narcissist in the country? Never mind that "alternative facts" don't exist.

But you know what? Sean Spicer totally killed his credibility and yours last Saturday when he stated unequivocably that you essentially were right and everyone else was wrong, and the media better stop making you look nothing like you see in the mirror. Narcissists do love to look at themselves, right? So, Sean Spicer will be working twice as hard to re-establish his credibility with the press. Sounds like if you didn't say it, it ain't real, huh?

Well, let's move on to this business of the illegal votes that gave Hillary Clinton the popular vote over you. I know that narcissists say that they tell it like it is, but really, Trump, after all that stuff about the inauguration, it's clear that you favor fantasy over reality because fantasy makes you look better.  Right?  And remember, facts are not fantasy.
I just love that tweet from Miriam Webster to KellyAnne Conway in response to her "alternative facts" comment: "A fact is a piece of information presented as having objective reality." Nothing about "alternative" or "fantasy" there, see?  Nothing but "objective reality."

So, the fact about the popular vote for the Nov. 8, 2016 election: Clinton won by 2.8 million votes. According to you, the most amazing narcissist in the country who favors fantasy because it makes you look better, those 2.8 million votes were cast illegally, either by dead people, people in the country illegally, or people who voted more than once, I guess.  Have you seen Jake Tapper's take on your belief about those 2.8 million votes?  It's here. He makes some important points about what you said, Trump, so you should be proud of saying what you said!

Here are his points:
-- When reporters asked your Press Secretary Sean Spicer about your claim, he said that you had "studies and information" about it but would not cite specifics or produce copies of the "studies and information."
-- If you have evidence of voter fraud of that magnitude, you are derelict as President not to order a major investigation into it, and so are the GOP leadership in Congress.

Jake Tapper (CNN)

Mr. Tapper went on to say:

"It would likely require a vast conspiracy involving public officials all over the country, and would likely have had far-reaching impact in other contests, tainting races down the ballot, not just the presidential race.

"If President Trump's beliefs are true, Republican leaders in Congress should be holding hearings and trumpeting this injustice every single day. His Justice Department, his Department of Homeland Security — all of them would need to crack down immediately.

"Unless of course, it's not even remotely true. Which is, of course, the case."

I know some election judges, by the way.  They are really offended by your allegations, Trump. They worked hard to insure that the election was free of fraud in their precincts. But I guess it doesn't matter to you, the most amazing narcissist who's concerned only about himself, that your allegations actually affect real people.

And finally, a fact: The Truth About Voter Fraud, a report written by experts at The Brennan Center for Justice, found voter fraud rates were between 0.00004% and 0.0009%.

So what you say about all those "millions" of illegal voters, and the possibility of voter fraud in our elections, looks an awful lot like you, the most amazing narcissist in the country, are totally trying to undermine democracy in the United States of America.

Who's your very first foreign leader to visit you as President, eh, Trump?
 

Thursday, January 19, 2017

The Successful Patient: Prior Authorizations

When I didn't need to go through the process of applying for new medical insurance this past December, I thought I'd have a quiet, smooth transition into the new year with my medical insurance. January, however, is the month for prior authorizations for medications. This year, my insurance company dropped three of my medications off its formulary of "accepted" medications. Last year, my doctor secured prior authorizations for two medications for me. The three are in addition to these two for a total of five medications for which I need a prior authorization.



What's a prior authorization or PA? It is the insurance company requiring an application for an exception to their formulary, or for a procedure or test that they don't normally cover. Sometimes, it's necessary to notify the insurance company before a surgery, hospitalization, or emergency room visit in order to get an approval to proceed and assurance that the insurance company will cover the cost. Someone at the insurance company reviews the application, looking for reasons that the medication is crucial for the patient's treatment, and based on that information, issues the decision to approve or deny coverage. Usually, the patient doesn't get involved in the process except to notify his doctor that a PA is needed for a specific drug or procedure. The doctor, or usually someone in her office, fills out the paperwork and submits it to the insurance company. The approval or denial will be sent to both the doctor and the patient. If denied, there is an appeal process that involves filling out more paperwork and submitting it.

I suspect that my experience as a patient is fairly common regarding PAs. Last November, I received notification from my insurance company that two of my medications would no longer be covered in 2017 and would need PAs. The two meds involved two different doctors. So, I called their offices, talked with their assistants and requested they submit PAs for the meds. I heard fairly quickly from one assistant who said the insurance company's response was that the med was covered. (We had decided to  wait with the second med.) So I called my insurance's customer service.

Dealing with customer service is always such a joy. I talked with a knowledgeable young woman that day who told me that my doctor's assistant had submitted the PA to the wrong place. So why wasn't the response to my doctor's assistant, "Sorry, you need to apply to this other place" instead of "The med is covered"? I did not say what I was thinking. I know about insurance company bureaucracy. It does not encourage independent thinking.  Anyway, the customer service rep told me that they'd instituted a new process for PAs, i.e. I could request them myself through customer service. So I did. For both of the meds. Pleased, I thought that'd be the end of it.

Ha.

At the end of December, I received another notification from my insurance company. This time, they informed me that three more medications had been dropped from the drug formulary for 2017. One of the meds was my B12 that I must inject every 3 weeks for the rest of my life because my body can no longer absorb the B12 from food or oral supplements. That just astounded me. B12?  Really?  And I loved the bureaucratic, rationalizing language in the notice: "These changes help keep health care costs as low as possible for everyone, while continuing to make sure you have access to safe, affordable and effective prescriptions."


I called customer service. Did not get the same knowledgeable young woman I got the first time. This rep was as mystified as I was by the notification. She told me two of the three drugs, including the B12, were on the 2017 drug formulary and covered. The third drug was not -- this one I wasn't concerned about because I had enough at home to cover me for 9-12 months. I'll deal with it next year. So why was I sent this notification that was clearly in error about two of the drugs? Who knows. It just added to my irritation.

But then, during the same phone call, I asked about the PAs I'd submitted earlier in the month. Now they were supposed to communicate with me and my doctors about their decision, right? None of us had heard anything. The rep told me that for one, they needed more information, and my doctor needed to call their "Pharmacy Benefits Manager" which is an entirely different company they've hired to manage their pharmacy coverage. She gave me the phone number for my doctor. The second PA application wasn't in their system. Nowhere. Gone. So, I did another one right then and there -- this was the third PA application for this particular medication. Now I was beyond irritation.


After calling my doctor and giving her nurse the phone number for the Pharmacy Benefits Manager, I prepared myself for two denials. The first one came about three weeks later, apparently by phone -- I found an automated call informing me of the "denial for the medication" I'd submitted the PA for on my voice mail. Did not specify the medication so I didn't know which one it was for. I went to the Pharmacy Benefits Manager website, signed in, and went to the PA page. There, at the bottom, was my name and a notice for the denial for the drug that they'd requested more information about. That drug had an alternative that was on the formulary, but I hadn't been keen on changing. I talked with my doctor's nurse about it, and she suggested that the Pharmacy Benefits Manager wanted me to try the alternative before they'd approve the PA for the drug I'd been taking successfully for nine years. I gave in and have switched medications.

Oh, but the fun wasn't over!  No. Another call came 3 days later, same automated format that didn't specify the drug, and left on my voice mail. I figured it must be for the second drug, the one of the 3 PAs. This drug did not have an alternative on their formulary; in fact, this drug is unique and stands virtually alone for treating the condition I have. So, we'd have to fight the denial. But then, 24 hours later, another automated phone call came telling me that the PA had been approved for one year. Huh? I went to the Pharmacy Benefits Manager website and sure enough, there at the bottom of the PA page, under my name, were 3 notifications: one approval, and 2 denials (1 denial for the approved drug posted 24 hours before the approval).

All through the two months of this process, I had in the back of my mind the saying, "The left hand doesn't know what the right hand is doing." Insurance companies outsource functions and as a result risk inefficiency, errors, and in my opinion, a LOT of stupidity. Ah, but it doesn't even end there!


Today, I received in the mail two written notifications from yet another "Pharmacy Benefits Manager" company that had reviewed PAs for one of my meds that had a PA last year. The first notification, dated Jan. 12, informed me that the PA was approved for Jan. 5, 2017 to Jul. 3, 2017.  The second notification, dated Jan. 16, informed me that the PA was approved for Nov. 17, 2016 to May 15, 2017. So I guess this means that my insurance will cover this med from Nov. 17, 2016 to Jul. 3, 2017. This Pharmacy Benefits Manager company reviews certain drug "requests" to determine if they are "medically necessary." Really? How the hell can they determine that when they have never talked with me, don't know my complete medical history like my doctor does, and have not been in direct consultation with my doctor. And is it really a doctor in the same specialty working for this company that makes the determination?

That makes 2 Pharmacy Benefits Manager companies for the one medical insurance company. It's all a bureaucratic mystery.