Insurance companies playing doctor

[christinequilts]

My insurance has decided they don't want to approve Lunnesta even though it cost the same as the Ambien I have been taking nightly for the past few years and is safer for long term use. My sleep doctor gave me samples a couple weeks ago so we could figure out what dose works best and I have to say I am sleeping better with Lunnesta then I was with Ambien though my sleep is still not great. My insurance has the brilliant idea that I should go back and try all the sleeping meds from square one again like Halcion, Restoril, and the like which are clearly not safe with severe Central Sleep Apnea but does the insurance company care? I would love nothing more then to not have to take sleep meds but until they can figure out a way to stop more of my Central apneas then BiPAP ST can (still have 30+ per hour with treatment) and severe Alpha Wave Intrusions I need medications that help me stay asleep during the night. Hopefully when my sleep doctor is at his main office tomorrow he can convince the insurance company that I truly do need Lunnesta but in the mean time his office is mailing me out more samples...I hate when some bureaucratic paper pusher thinks they know what is better for me then my own doctor.

[ozij]

Oh $%&@!!!
Those paper pushing idiots. I wish you didn't have it so difficult.
O.

[bikernc]

Most insurance companies have in house " information" from Drug manufacturers etc....so they ( the ins co) think they know best.
Good example...My ENT doc has me taking Nexium 2x daily...the insurance company "advised" me this was twice the manufacturers recommended dosage
and stated the Doctor had to write before they would approve the prescription.
Of course, the Doc was furious and called BCBS, was not pretty. Anyway BCBS did "approve" the dosage... and suggested I try going to zantac or pepsid as a cheaper alternative....Neither drug did anything for me....
BCBS also did not want me to take Lunesta, but Ambien ....THe Doc advised the rep at BCBS, that I had not done well with Ambien. In both cases, the doctors filed complaints . re. Insurance companies second guessing their
professional judgement etc........
So, have the Doctor call the "Provider"...you may get results.

[unclebob]

Hi christinequilts,

You have raised a really serious issue that needs exploring. It is my understanding that insurance companies will only reimburse the cost of a generic drug to the one prescribed unless the doctor specifically prescribes a particular brand and may even have to note this on the prescription. The insurance company is only trying to save a buck if the medication is substantially similar. Nothing really wrong with this. But if the doctor prescribes a particular brand of a medication to achieve patient well being then the insurance company should provide coverage.

The question may be - are you dealing with an ambitious penny pinching paper pusher or bumping up against company policy that dictates via your insurance agreement what you are entitled to and the company's options as to what extent they have to respond.

I guess this means you not only need a doctor and a pharmacist and an insurance company but also a non evil lawyer. Feel any better now?

Life is not only a roller coaster but a ferris wheel and a merry go round as well. You never really know where the hell you are at any given time!

Hope you get this sorted out to your satisfaction.

Bob F

[rested gal]

No wonder so many people are on blood pressure meds. It's things like what you've run into, Christine, that send a nice normal BP skyhigh. Whew.

[christinequilts]

You have raised a really serious issue that needs exploring. It is my understanding that insurance companies will only reimburse the cost of a generic drug to the one prescribed unless the doctor specifically prescribes a particular brand and may even have to note this on the prescription. The insurance company is only trying to save a buck if the medication is substantially similar. Nothing really wrong with this.

What my insurance will cover and not cover prescription wise doesn't make sense 90% of the time. Because I have a feeding tube I need the regular release version of one of my meds instead of the brand name slow release version. Every 12 months my doctors office has to go through the process to get a prior authorization for me to use the $10 per month genric version instead of the $150 per month brand name slow release. Since my copay would basically be the same either way I could go ahead and use the more expensive version but what is the point when the med has to be crushed to go through my feeding tube? The other good one is one of my nausea meds, zofran. I can only get 15 tablets per prescription fill which means I have to get it refilled once a week...it was twice a week at one point until my doctor figured out she could write for me to take 1/2 of an 8mg tablet instead of a 4 mg tablet that I was getting so I effectively get 30 doses per script. I understand trying to be cautious due to the extremely high cost of this med and limiting the total script amount on new scripts but I have been on this med for over 2 years. Luckily my pharmacy isn't far from my house and I have great pharmacist but it would be nice to go more then a week without having to see him.

[ejdischer]

I recently moved up to CT from NJ. At my old station, my insurance was United Healthcare. Prior to that, my wife had Horizon. Up here, we have Cigna. Or as I prefer to call it: Nothing At All. On my wife's end of things, she takes Celebrex for menstrual migraines. However, Cigna will not approve that drug because it "isn't approved use." Our other insurance companies had no problem with it.

On my end of things, I can only deal with Apria for my OSA. Getting my machine was a month long issue because I needed a "medical reason" to have a travel-sized device. Apparently traveling a lot isn't good enough for that. Getting a hybrid was equally hard and I actually got my machine over a week before I got my mask. Something about, "your machine is on order but we can't get the mask until we have the machine." Because of course it wouldn't make sense to order both at the same time.

Anyway, insurance companies can be frustrating. This is why you must be diligent and do your own leg work sometimes. But it's worth it. And it's only getting worse. I went from a local TV station in NJ to the largest Sports TV network in the world. My insurance is now twice as expensive and half as good.

EJD

[KimberlyinMN]

My brother has three cracked teeth and needs crowns on all of them and his dental insurance (Delta Dental) is refusing this as they are deeming this "cosmetic"... Uh, what? I suppose it would be considered cosmetic as opposed to having them pulled. (Because the crowns would be much nicer to look at.) Then again, insurance companies pay for viagra but not all states require insurance to pay for birth control.

That is insane that your insurance won't pay for the new med but wants you to start over with all of the other ones. Wouldn't that end up costing them more money in the long run? I hope your doctor is able to call them or write a letter.

Kimberly

[jum001]

The insurance company isn't doing anything medical. They are abiding by the legal terms contained in the contract called an insurance policy. There is often a difference between what we feel should be in the contract and what actually is in the contract. The contract terms are one size fits all unless you can show there should be an exception in your case. Your doctor is the person who can show why there should be an exception and, yes, it does drive the doctors over the edge and it doesn't always work. That something isn't right or isn't fair makes little difference. The terms of the contract will govern. That said, the first level customer service reps have minimal knowledge of the terms and no authority to deviate from them. Always take an unresolved complaint to the highest appeal authority you or your medical provider can reach.

[Yoga]

Christine,

Sorry to hear about your problems.

Have you tried Ambien CR? Plain Ambien did not work for me but Ambien CR (controlled release) does.

[UncleLeo]

Hi christinequilts,
The insurance company is only trying to save a buck if the medication is substantially similar.

While I don't doubt this is true, it does seem ironic when they don't seem to care that they get gouged so badly on cpap machines from local DMEs when there are obviously better and cheaper alternatives.

[Bearded_One]

My insurance has decided they don't want to approve Lunnesta even though it cost the same as the Ambien ... I hate when some bureaucratic paper pusher thinks they know what is better for me then my own doctor.

Your insurance company is not "approving" which medications you take, they are telling you which medications they will pay for. Many insurance companies have formularies that specify what medications they will cover. It sounds like Lunesta is not on their formulary, but Ambien is. The insurance company is not saying that the doctor has to prescribe Ambien, the insurance company is saying that it will not pay for a medication that is not on their formulary. Your insurance policy will specify what sort of coverage you have.

[Wulfman]

And......this thread is about a year and a half old. (if that matters)

Den