The Insurance Industry Has Us By the Balls!
I was engaged in a fight with my insurance company that I lost. Our prescription insurance is refusing to cover my son's allergy medication. He takes Zyrtec every day for seasonal and other allergies. Our new prescription insurance says that because he has never tried the over the counter alternative, Claritin, they won't pay for his Zyrtec. To buy the prescription medication without coverage, it would cost us $59.59 per month.
His pediatrician contacted the insurance company to get them to pre-authorize his prescription. They refused. The doctor's office offered to fax them my son's medical file, which is inches thick because of all of his allergy issues. The insurance company hung up on my doctor's office. I contacted his allergist, wondering if she would have any advice, since she was the original prescriber of his medicine almost six years ago. Her office told me that the insurance companies are getting more and more strict and that there was nothing we could do. I talked to a pharmacist who told me to lie...how would the insurance company know whether we tried the OTC medication or not?
Finally, the pediatrician suggested that she write a letter of appeal to the insurance company. She would state in it all of the reasons that my son's medication should not be changed. My husband and I liked this alternative best, but the more we thought about it the more convinced we became that it would not make a difference. Unfortunately, by the time that letter was received, reviewed and most likely denied, we would be into the beginning of the school year. How can I change my son's medication when he is going to be out of the house for more hours than he is in it? So, by default, timing and resignation, the insurance company won. If my son is to safely try a new medication for 30 days, we have to do it now. I can't have him going to school miserable if the medication doesn't work.
So off I go on a hunt for the OTC medication. The doctor said we could use the generic or the brand name Claritin, and we could by the syrup or the fast melt tabs. Okay, I had no idea how expensive that stuff is. The fast melt tabs come four in a pack and cost over $4. To give my child a month's supply of that medication it would cost over $30. The syrup is much more reasonable at around $8 for the brand name and $6 for the generic. But that is only a 12 day supply. A month's worth of the generic syrup costs around $15. That is more than I was paying before for the Zyrtec. All of this comparing prices has me feeling guilty. We are talking about my son's health and well-being. Money shouldn't be an issue. But it is. I have to think about it. I have to find the best deal for this medicine out there, because it is going to start costing us more than the prescription did, before our insurance company decided to assert that they know more about my son's medical conditions than his pediatrician or his allergist.
So, I bought the generic syrup. For two days my son has taken it. So far, his allergies are being kept at bay. No watery, itchy eyes, no itchy runny nose. Great...except that he hates the taste of the damn syrup and I have to fight him to get him to take it.
Since when do insurance companies know more than doctors, specialists and pharmacists? I am so frustrated at the fact that a medication that my son's allergist said was "the best one out there for allergies" is being denied to us. How is that good health care? When my son started taking Zyrtec, Claritin was still a prescription medication. There is a reason that his allergist prescribed Zyrtec. Because it works better. But now we have to try the less effective alternative because the insurance company doesn't want to pay for his medicine anymore.
I actually got a letter recently from the insurance company explaining which drugs it covers and why those drugs are on the "preferred list". Obviously I knew it was all about money. But to have that so shockingly thrown in my face in this letter was even more infuriating. The letter actually states that they make decisions about which drugs to place on the preferred list based on rebates and kick backs that they get from drug manufacturers. Then it goes on to state that even if they are getting a rebate for a drug that you are taking, they don't pass that cost savings on to you. What?
So we pay an incredible amount of money every month for insurance coverage and the insurance company does not pass on cost savings on certain drugs to us. So my son has to take a medication that may not be as effective in fighting his allergies because the insurance company isn't getting any kick backs from Pfizer (the makers of Zyrtec). And there isn't anything we can do. We have to have insurance. Many people don't even get a choice because their employers may only offer one plan. Unless you go out on your own and pay even more money for an individual plan. They have us by the balls!
And they won. That makes me even more frustrated than anything else. They won. I switched his medicine to see if the OTC would work better because there wasn't anything else I could do. Other than spend $60 a month for the prescription medication, and we can't afford that. Right now, I am pretty frustrated with the state of health care that we receive. The insurance company gets to push us around and we can't do anything about it. It is all about money. Might as well bend over if you don't have it. Pretty sad and depressing.
His pediatrician contacted the insurance company to get them to pre-authorize his prescription. They refused. The doctor's office offered to fax them my son's medical file, which is inches thick because of all of his allergy issues. The insurance company hung up on my doctor's office. I contacted his allergist, wondering if she would have any advice, since she was the original prescriber of his medicine almost six years ago. Her office told me that the insurance companies are getting more and more strict and that there was nothing we could do. I talked to a pharmacist who told me to lie...how would the insurance company know whether we tried the OTC medication or not?
Finally, the pediatrician suggested that she write a letter of appeal to the insurance company. She would state in it all of the reasons that my son's medication should not be changed. My husband and I liked this alternative best, but the more we thought about it the more convinced we became that it would not make a difference. Unfortunately, by the time that letter was received, reviewed and most likely denied, we would be into the beginning of the school year. How can I change my son's medication when he is going to be out of the house for more hours than he is in it? So, by default, timing and resignation, the insurance company won. If my son is to safely try a new medication for 30 days, we have to do it now. I can't have him going to school miserable if the medication doesn't work.
So off I go on a hunt for the OTC medication. The doctor said we could use the generic or the brand name Claritin, and we could by the syrup or the fast melt tabs. Okay, I had no idea how expensive that stuff is. The fast melt tabs come four in a pack and cost over $4. To give my child a month's supply of that medication it would cost over $30. The syrup is much more reasonable at around $8 for the brand name and $6 for the generic. But that is only a 12 day supply. A month's worth of the generic syrup costs around $15. That is more than I was paying before for the Zyrtec. All of this comparing prices has me feeling guilty. We are talking about my son's health and well-being. Money shouldn't be an issue. But it is. I have to think about it. I have to find the best deal for this medicine out there, because it is going to start costing us more than the prescription did, before our insurance company decided to assert that they know more about my son's medical conditions than his pediatrician or his allergist.
So, I bought the generic syrup. For two days my son has taken it. So far, his allergies are being kept at bay. No watery, itchy eyes, no itchy runny nose. Great...except that he hates the taste of the damn syrup and I have to fight him to get him to take it.
Since when do insurance companies know more than doctors, specialists and pharmacists? I am so frustrated at the fact that a medication that my son's allergist said was "the best one out there for allergies" is being denied to us. How is that good health care? When my son started taking Zyrtec, Claritin was still a prescription medication. There is a reason that his allergist prescribed Zyrtec. Because it works better. But now we have to try the less effective alternative because the insurance company doesn't want to pay for his medicine anymore.
I actually got a letter recently from the insurance company explaining which drugs it covers and why those drugs are on the "preferred list". Obviously I knew it was all about money. But to have that so shockingly thrown in my face in this letter was even more infuriating. The letter actually states that they make decisions about which drugs to place on the preferred list based on rebates and kick backs that they get from drug manufacturers. Then it goes on to state that even if they are getting a rebate for a drug that you are taking, they don't pass that cost savings on to you. What?
So we pay an incredible amount of money every month for insurance coverage and the insurance company does not pass on cost savings on certain drugs to us. So my son has to take a medication that may not be as effective in fighting his allergies because the insurance company isn't getting any kick backs from Pfizer (the makers of Zyrtec). And there isn't anything we can do. We have to have insurance. Many people don't even get a choice because their employers may only offer one plan. Unless you go out on your own and pay even more money for an individual plan. They have us by the balls!
And they won. That makes me even more frustrated than anything else. They won. I switched his medicine to see if the OTC would work better because there wasn't anything else I could do. Other than spend $60 a month for the prescription medication, and we can't afford that. Right now, I am pretty frustrated with the state of health care that we receive. The insurance company gets to push us around and we can't do anything about it. It is all about money. Might as well bend over if you don't have it. Pretty sad and depressing.
posted by mother juggler @ 10:36 AM
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