La Condessa Posted March 25, 2015 Share Posted March 25, 2015 My youngest son has breathing problems, probably severe asthma, for which he sees a pediatric pulmonologist. He has been tested for various things, had pneumonia, in the past been on several nebulizer medications up to seven treatments per day to control it, plus courses of steroids when that didn't keep it under control. But lately, he's been doing way better. Almost a month ago we decided to try switching him to two different medications on a metered dose inhaler, to compare and see if he did better. (One maintenance medication, one immediate response to breathing difficulty). He has gradually but steadily improved since then, needing fewer and fewer doses of the immediate medication, and now this past week, we've even been able to drop his maintenance med down to once a day! It is the first time in over seven months he has been able to breathe so easily with so little medical intervention. It is just wonderful. Today, I received a letter from my insurance company saying that as of May 1st, they will no longer cover his maintenance inhaler medication. They had a short list of other medications they said could be used instead, and it did say that if the patient has tried two of those other medications and they have both proven ineffective, they can apply for an exception. Seriously? They want us to take a baby who's spent two thirds of his life fighting for breath off of the medication we've found that works for him!? I have an idea, how about THEY spend a month breathing through a straw while they try out various medications to try to save someone a few bucks!! And if it sets him back again, and we have to step up the visits with the specialist at the children's hospital? If he gets pneumonia again, needs more chest x-rays? Winds up being hospitalized? How exactly is dropping coverage for his medication likely to save them money with all of that on the line?! Quote Link to comment Share on other sites More sharing options...
creekland Posted March 25, 2015 Share Posted March 25, 2015 I think it would be worth it in your situation to try an appeal now. I've no idea what the odds of it being successful would be, but it'd be worth a try. Sometimes one wonders what sort of thought process the powers that be put into these decisions. :banghead: And :grouphug: that you have to deal with it all in addition to the actual medical issue. 3 Quote Link to comment Share on other sites More sharing options...
whitestavern Posted March 25, 2015 Share Posted March 25, 2015 You might try asking your doctor to intervene. He/she can contact the insurance company and share the treatments you've tried and where your child is at now. Sometimes they will end up deciding to cover. 4 Quote Link to comment Share on other sites More sharing options...
kewb Posted March 25, 2015 Share Posted March 25, 2015 I am so glad you found a med that works for your baby. I would start the appeal process right now. If there is one thing I have discovered on my husband's health journey it is that sick people need a healthy person who can be their advocate. Dealing with insurance is a nightmare. 3 Quote Link to comment Share on other sites More sharing options...
kiana Posted March 25, 2015 Share Posted March 25, 2015 Yeah, I'd start appealing now and get a nasty-gram from your doctor as well outlining all the things that could happen to a baby who can't bloody well breathe. 1 Quote Link to comment Share on other sites More sharing options...
Twigs Posted March 25, 2015 Share Posted March 25, 2015 :grouphug: :grouphug: :grouphug: Quote Link to comment Share on other sites More sharing options...
plansrme Posted March 25, 2015 Share Posted March 25, 2015 The insurance companies require step therapy and formularies (you are the victim of a formulary) to keep prices under control. Doctors who prescribe medications aren't paying for them and often have no idea how much they cost, so they can prescribe the bright, shiny new Cadillac when the battered Corolla works just as well for all or some of their patients. Of course the Cadillac dealer is marketing the heck out of their Cadillac, plying the doctor with note pads and pens and, for the really expensive stuff, golf outings in the name of "education." Drug companies have patents on their new Cadillacs and can charge whatever the market will bear, but when the consumers, i.e., you and the doctor in this case, are not paying that price, the market doesn't work. Sure, the Cadillac may have some feature you want--the navigation system, for instance, but for many drivers, the Corolla is just fine. This is why there is an appeals process, though: it is your chance to show them that you need the navigation system. They've given you five weeks to prepare your appeal, and you have a good shot at winning it. They may even continue to pay for the drug while your appeal is pending. The company is not doing this to be mean; they don't know your kid's story. They are just trying to keep drug costs in check, which will help keep your premiums from being a billion dollars a year. I don't blame you for being annoyed (I've ranted about my share of stupid mailings from insurance companies, most recently the one in which they refused to pay for my daughter's ACL surgery until I filled out something saying she was not in a car accident; really--who tears an ACL in a car accident???), but if you can clearly lay out the facts above, you will probably end up right where you want to be. If not, you can always self-pay; I suspect that if you do that, though, you're going to find out why the drug is not on the insurance company's formulary, but you could always try to find a discount program from the manufacturer. 5 Quote Link to comment Share on other sites More sharing options...
Spryte Posted March 25, 2015 Share Posted March 25, 2015 Has your kiddo tried the medications on the list already? Even if not, I think your child's doc can intervene here. I'm so sorry. Start the appeal process now, with your doc on your side. Hopefully this will work, and quickly. And if there is a lapse in coverage, perhaps your doc has samples and can give you enough to get through? But also ... very happy that you've found something that works! We went through similar agonies with our kiddo, and it was just awful. The relief, 2 years ago, when we found the right med combo... Oh, there's no describing it. My guy takes 2 maintenance inhalers and a nasal spray. So 3 meds plus emergency inhalers and neb meds as needed. Our insurance is essential! Those meds are expensive. Ouch. I would have a minor freak out if we'd received your letter. :grouphug: Quote Link to comment Share on other sites More sharing options...
Goldilocks Posted March 25, 2015 Share Posted March 25, 2015 Our insurance stopped covering a something used by my son. All it took was a letter from the doctor to get it covered again. 1 Quote Link to comment Share on other sites More sharing options...
Tammyla Posted March 25, 2015 Share Posted March 25, 2015 I agree with calling the dr. office and see if they can offer help. Poor baby, I hope it works out without a huge headache. Quote Link to comment Share on other sites More sharing options...
La Condessa Posted March 25, 2015 Author Share Posted March 25, 2015 Thanks, everyone. I do understand why insurance companies do this, I'm just upset about it right now. And I know that I need to start the process to try to get an appeal, but I am really, really introverted and nonconfrontational irl. So my stomach is twisting up in knots as I think about this and how I need to approach it to be an effective advocate for my son. And I'm worrying, if we can't get them to cover it without switching to other medications for a time first, do we actually do that, or do we just say we'll pay out of pocket, then? And is there any way we can actually come up with the money to do that? Ds was on Budesonide inhalation suspension with the nebulizer in the past, which is the generic name for Pulmicort Repules. One of the listed alternative medications is Pulmicort Flexhaler, so I'm not sure if they will count that or not. Also, I'm not sure whether they will consider it to have been ineffective. Once they upped his dosage on that medication, he went three months needing only one course of steroids (that one 2xs per day plus his other medication 3 or 4xs most days). Quote Link to comment Share on other sites More sharing options...
Jean in Newcastle Posted March 25, 2015 Share Posted March 25, 2015 Talk to the doctor. File for the exception. But first a :grouphug: and some virtual chocolate. Quote Link to comment Share on other sites More sharing options...
AK_Mom4 Posted March 25, 2015 Share Posted March 25, 2015 I recently went thru the appeal process for one of my meds that I take daily. My doctor had a form letter already that she filled in the details for this medication and my medical history and sent it to the insurance company. I filled out a similar form online and submitted it. The appeal process was very quick in my case and my medication is now fully covered for the next twelve months. I will have to have forms resubmitted then if I still need it. I would start the process now. They did have other meds on their list for me, but my doctor did not feel they were good choices in my case and put that info in the letter. I did not have to try other drugs first. 1 Quote Link to comment Share on other sites More sharing options...
Guest Posted March 25, 2015 Share Posted March 25, 2015 The insurance companies require step therapy and formularies (you are the victim of a formulary) to keep prices under control. Doctors who prescribe medications aren't paying for them and often have no idea how much they cost, so they can prescribe the bright, shiny new Cadillac when the battered Corolla works just as well for all or some of their patients. Of course the Cadillac dealer is marketing the heck out of their Cadillac, plying the doctor with note pads and pens and, for the really expensive stuff, golf outings in the name of "education." Drug companies have patents on their new Cadillacs and can charge whatever the market will bear, but when the consumers, i.e., you and the doctor in this case, are not paying that price, the market doesn't work. Sure, the Cadillac may have some feature you want--the navigation system, for instance, but for many drivers, the Corolla is just fine. This is why there is an appeals process, though: it is your chance to show them that you need the navigation system. They've given you five weeks to prepare your appeal, and you have a good shot at winning it. They may even continue to pay for the drug while your appeal is pending. The company is not doing this to be mean; they don't know your kid's story. They are just trying to keep drug costs in check, which will help keep your premiums from being a billion dollars a year. I don't blame you for being annoyed (I've ranted about my share of stupid mailings from insurance companies, most recently the one in which they refused to pay for my daughter's ACL surgery until I filled out something saying she was not in a car accident; really--who tears an ACL in a car accident???), but if you can clearly lay out the facts above, you will probably end up right where you want to be. If not, you can always self-pay; I suspect that if you do that, though, you're going to find out why the drug is not on the insurance company's formulary, but you could always try to find a discount program from the manufacturer. Yup. I'm self paying my epipens which are $400 a pop, but they're necessary. Definitrly try to appeal it, but sometimes it just becomes a budget item to afford medication. If no other treatment works, that's life :(. One things yoy may look into is contacting the manufacturer directly. Many have discount programs for cash strapped patients. Quote Link to comment Share on other sites More sharing options...
Spryte Posted March 25, 2015 Share Posted March 25, 2015 Yup. I'm self paying my epipens which are $400 a pop, but they're necessary. Definitrly try to appeal it, but sometimes it just becomes a budget item to afford medication. If no other treatment works, that's life :(. One things yoy may look into is contacting the manufacturer directly. Many have discount programs for cash strapped patients. I hope you are not paying full price. There are many coupon/discount options for epipens. Here's the $0 co-pay card: https://www.epipen.com/copay-offer/ That covers your co-pay up to $100 for up to 3 epipens at a time. If you are uninsured, there are coupons to cover that, too. It looks like Auvi-Q has the same $0 copay deal, and I know they have alternate coupons for the uninsured as well. https://www.auvi-q.com/sign-up?s_mcid=AVQCO20423PS&MTD=2&ENG=1&QCPN=2 We only use Auvi-Q these days, and have no copay, but our allergist always offers us coupons etc. We were just there on Friday, and she mentioned them again. Since we don't need them, I don't take her up on them, but it's nice to know they are out there. Quote Link to comment Share on other sites More sharing options...
Guest Posted March 25, 2015 Share Posted March 25, 2015 The epipen and auvi-q one doesn't work for us because they require insurance in order to offer the copay discount. The auto injector ones would work, but our local pharmacy doesn't stock the items. Next time I go I'm going to harass them about special ordering for me, and my provider has already said she will write a prescription specifically for those other brand, because yes, we are paying full price for them right now. And I had a series of severe reactions and ended up using three of them in four days a few weeks back :( Quote Link to comment Share on other sites More sharing options...
redheadmom Posted March 26, 2015 Share Posted March 26, 2015 Yup. I'm self paying my epipens which are $400 a pop, but they're necessary. Definitrly try to appeal it, but sometimes it just becomes a budget item to afford medication. If no other treatment works, that's life :(. One things yoy may look into is contacting the manufacturer directly. Many have discount programs for cash strapped patients. I'm not sure if this would help you but have you looked at online pharmacies. A few years ago a family member couldn't afford their prescriptions so I researched and found one in Ohio. You must have a prescription but for many things they are more affordable. Www. Health warehouse.com My family member has used them for years with no major issues. Good luck. Quote Link to comment Share on other sites More sharing options...
HSmomof2 Posted March 26, 2015 Share Posted March 26, 2015 Thanks, everyone. I do understand why insurance companies do this, I'm just upset about it right now. And I know that I need to start the process to try to get an appeal, but I am really, really introverted and nonconfrontational irl. So my stomach is twisting up in knots as I think about this and how I need to approach it to be an effective advocate for my son. And I'm worrying, if we can't get them to cover it without switching to other medications for a time first, do we actually do that, or do we just say we'll pay out of pocket, then? And is there any way we can actually come up with the money to do that? Ds was on Budesonide inhalation suspension with the nebulizer in the past, which is the generic name for Pulmicort Repules. One of the listed alternative medications is Pulmicort Flexhaler, so I'm not sure if they will count that or not. Also, I'm not sure whether they will consider it to have been ineffective. Once they upped his dosage on that medication, he went three months needing only one course of steroids (that one 2xs per day plus his other medication 3 or 4xs most days). You don't need to be confrontational at all. You just need to submit the facts. This really all needs to be done in writing, and primarily from your doctor. Contact the doctor's office and ask them to send in an appeals letter explaining why this medication is medically necessary for your child. Medical offices deal with this all the time. Also, your can submit your own letter of appeal to the insurance company. Then, follow up with your doctor's office/insurance company for updates. Try not to worry yet, this is a normal (albeit frustrating) part of dealing with doctors and insurance. There is usually a second and third level of appeals as well, if the first one is denied. (I spent 3 years responding to appeals and authorization requests for a large medical insurance company, after working for 4 years doing insurance referrals for a medical office.) 1 Quote Link to comment Share on other sites More sharing options...
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