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lexi

Insurance annoyance

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So my toddler has a raging fever and very red throat. I took her to urgent care. Rapid strep was negative but dr felt she did have strep. I opted not to culture it but to just treat it since she had all the signs of strep. 

Then my insurance denied coverage of her antibiotic. Why? What is their problem? 

I’m over all of this. I just had a dry drowning scare with this kiddo and spent last weekend in ER. Then all of my kids had a horrific stomach virus. And me too. I’m just so done. Bah humbug. I’m so grouchy. 

Thankfully it’s nothing serious and the meds are not super expensive and I have so much to be thankful for. But just ugh. I needed to vent. 

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9 minutes ago, lexi said:

So my toddler has a raging fever and very red throat. I took her to urgent care. Rapid strep was negative but dr felt she did have strep. I opted not to culture it but to just treat it since she had all the signs of strep. 

Then my insurance denied coverage of her antibiotic. Why? What is their problem? 

 

They want proof it's needed.  ETA:  Didn't think this through.  They wouldn't even know yet if tests had been done.  See below.

Edited by klmama

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Is it denial of all antibiotics?  (Highly unusual). This particular antibiotic?  (In which case the pharmacy can call the doctor to ask for an alternative). Or brand name vs generic?  (Very common and again solved by a pharmacy call to the doctor). 

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It’s amoxicillin. My other daughter was just on this very antibiotic 5 weeks ago. They covered hers. 

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Can your doctor appeal the decision for you?  I have had doctors do that (though this is mostly for acne medication). 

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My husband went to pick up the meds. 

I’m currently calling the pharmacy to get more details. 

 

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It may be that your dd's insurance info didn't get plugged into the pharmacy's system correctly.  One of my dc had a Rx denied for not being insured - it turned out they'd typed one number incorrectly.  

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The insurance won’t tell the pharmacy why they’re denying it. I can’t call the member line because they’re closed today. 

The pharmacist guesses it might be beamed on the strength of the antibiotic. It’s a different strength than what was prescribed for my other daughter last month. 

But she said the one that was prescribed is an extremely common strength so this doesn’t make any sense to her. 

What insurance won’t cover the pink bubblegum medicine? 

They won’t cover my Epi pens or Auvi-q’s. Grrr! Now this! 

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9 minutes ago, Jean in Newcastle said:

Your insurance company website should have a list of allowed medications. Pink bubblegum is not a specific medication- it is a flavoring added to all kinds of prescription meds. 

I think she is just saying that amoxicillin, which (iirc) is a pink liquid, is something that's usually covered.  

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9 minutes ago, Jean in Newcastle said:

Your insurance company website should have a list of allowed medications. Pink bubblegum is not a specific medication- it is a flavoring added to all kinds of prescription meds. 

I know. I was referring to the pink amoxicillin. It’s the common antibiotic for kids. 

They covered amoxicillin for my other daughter last month. But not for this child. It makes zero sense. 

It’s the most common antibiotic....

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Just now, marbel said:

I think she is just saying that amoxicillin, which (iirc) is a pink liquid, is something that's usually covered.  

Yes. That’s what I’m saying. It’s very common and has always been covered in the past. 

I know that the meds are not called pink bubblegum. But that’s how everyone knows them and how I remember them from childhood. 

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Sometimes it's not the drug itself but the way the pharmacy is processing it. Quantity issues are very common, too short of a days supply could cause a rejection. I work for a large insurance company and handle all pharmacy issues so I see how claims are rejecting. Just an idea to consider as it's not always that your insurance is just denying it.

Edited by mommybee
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The pharmacy could have called the insurance to ask why it was denied. I am surprised they didn't unless the insurance gave them a crystal clear denial.....and then the pharmacy would know why it was denied.

I am a pharmacy tech. My gut instinct says it was a high dose alert, because we often get them with liquids for kids because we have to fill full bottle quantities.  For example. If the doctor writes "give 5mls three times daily for 10 days, dispense 150mls" I may not have a stock bottle that has 150mls.  So, we generally use 2x100ml bottles (total of 200mls), type the instructions as the doctor wrote and tell the insurance that it will last 10 days since that is the limit the doctor wrote on the script. The insurance doesn't look at the instructions in this step of the processing, they just divide the total dispensed by the days supply. The insurance may have been fine with 15mls total per day as the doctor wrote it, but see that 20mls per day (200ml/10days) is too high of a dose.  We have an override we can put in to bypass the denial, but not everyone knows it off the top of their head.  They would have had to call  the insurance company to find that out how to fix the high dose alert.

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