Friday, January 24, 2014

A Bumpy Ride: Transitioning to my new Medical Insurance Coverage

Effective January 1, 2014, my new medical insurance coverage kicked in.  Yay!  Maybe there are thousands of other people who can say the same thing.  For the last three weeks, I've been learning just what that means in terms of my life and health.

First up: I had been very careful to check the insurance company's drug formulary for my plan to insure that all my medications were on it.  All but one, Restasis, was on the formulary.  Yay!  I made an assumption that even though Restasis wasn't on their formulary, they would still pay 60% of the cost, as my former insurer had done.  More on this later.  The first issue that popped up quite fast concerned a formulary drug.

That drug falls into the "specialty" category because of its cost.  This meant that I needed to switch my specialty pharmacy to the one my new insurer uses.  I was disappointed that I had to leave the specialty pharmacy my former insurer used because they had done an excellent job supporting me and delivering my medication.  But I have a new insurer, so I called the new specialty pharmacy and gave them the information to request transfer of my prescription from the other specialty pharmacy.  That process occurred without a hitch.

But then, my new insurer required a prior authorization for the medication, even though it's on their formulary.  This involved numerous phone calls to the insurer, my doctor, e-mails, and finally follow-up calls because my new insurer doesn't call patients when a prior authorization decision has been made.  Fortunately, we received approval and the prior authorization for a year.  My new specialty pharmacy proceeded to deliver the medication to me in time for the next dose administration.

Next up, my Restasis prescription.  The medical reason for this prescription is to treat dry eyes as a result of Sjogren's Syndrome which is an autoimmune disease.  You may have seen the TV commercials for this drug, and the most common usage is for "chronic dry eye disease."  I'm not certain what that is, but I don't think it's the same as what I have.  I called in my refill request to my local pharmacy.  They could not process the refill through my insurance.  It wasn't covered.  Hmmmmm.  My pharmacist suggested we do a prior authorization, so again, I was on the phone with the insurer and my doctor's office, getting the prior authorization process going.  Meanwhile, I am running out of the medication.  My eyes are becoming inflamed (reddened with little veins sticking out) because I'm using the Restasis only once a day to make it last.  I use artificial tears about once an hour to keep my eyes moist.  I am waiting for the prior authorization decision, but my expectation is zero that we'll get approval.


Why?  Well, it goes back to the plan that I purchased.  It covers vision care for children under 18, but not for adults.  I saw this and understood it.  I expect to pay for my vision check-up this summer out of pocket.  I had not expected it to include the Restasis.  But the more I think about it, the more I expect them to deny the prior authorization.  Unfortunately, I cannot afford this medication out of pocket monthly, a cost that runs about $440 per month.  I will ask my ophthalmologist if there's a cheaper alternative.

When I called in the Restasis refill, I also called in two generic refills, medications that I've been taking for over five years.  At the pharmacy, they informed me that my insurance covered only one of them.  For the other, Ranitidine, the pharmacist offered to fill the prescription using tablets instead of capsules to save me 50%.  I agreed.  Ranitidine, which I take for GERD, is on my new insurer's formulary.  So why didn't they cover it?

Back to my plan contract and the exclusions section.  There I found an entry that said they would not cover medication, generic or brand, that was close to an over-the-counter medication.  In other words, they want me to buy the Ranitidine over the counter, which I could -- it's the generic for Zantac -- but it's cheaper to have it prescribed.  I've never sat down to figure out my exact savings, but it's more than enough to justify the prescription.  So, why doesn't my new insurer agree with this strategy to save money?  Because they don't cover over-the-counter medication (most insurers don't) and that saves them money.

I have yet to step inside one of my medical team's offices.  I'm hoping that once I get the medication issues ironed out, I won't have any more problems with my new insurer.  I've read carefully the coverage for all my medical check-up needs and hospitalization (which I'm doing everything possible to avoid), etc.  I think it'll be just fine.

Now, if I can just have the Restasis prior authorization approved....

Update: Just to keep things interesting....  I called my insurer to inquire about the status of the prior authorization.  The application was not in their system.  They did not receive it.  %&^!#!!%  I called my doctor's office and left a message.  His assistant called.  She sounded apologetic but frazzled, which seems to go with talking with insurance customer service.  She has re-sent the application by the method they requested.  So now, we wait.  I'll run out of my current supply on Monday....

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