I am ridiculously healthy, which I attribute to both good luck and determined effort. But I am one of the 10-13% of the American population who gets migraines. Given that proportion, if you don’t have them yourself, most likely you know someone who does.
There really is no such thing as a “mild” migraine, though they do range in intensity to extreme. They are disruptive by their nature. A few years ago, by luck, I was prescribed a medicine that takes the pain away. (I say “luck” because not everyone finds a solution that works for them.) I want to be clear, it doesn’t take the migraine away. But it makes the headache very tolerable for me. That prescription made my work life possible, as really no one gets 40-60 paid sick days a year, every year, for years on end.
Due to multiple circumstances, I hadn’t purchased that prescription using my current insurance. This spring was the first time, with this insurer, that I tried to. My prescription was denied. They would not cover it.
Instead my doctor and I each received notification that the insurer has a list of four approved migraine medicines in the same class. In order to consider an appeal to cover the one we know works, I would need to FAIL with at least three of the four approved ones. While this notice was frustrating, I’m game. If I can buy something that works as well and is cheaper for me and cheaper for the insurer, I’m all for that.
In fact, one of those four was the first thing prescribed for me years ago. It did not work. Strike one. So I only needed to fail at two more, or better yet, have one of them work, to stop the process. I thought…
In the following months my doc prescribed two others on the list. Neither works. Let me repeat: NEITHER WORKS. In fact, two of the worst headaches I’ve had in recent years were when trying them. Strikes two and three.
The doctor again prescribed the one we know works. The prescription was denied. Before the insurer will pay, they first need to consider the merits of my need. In other words, I need to file an appeal. Yes, that’s right. Covering the good one is not automatic. I need to appeal.
The doctor submitted an appeal, based on the criteria the insurer set out, that I needed to fail on at least three of four approved meds. It was denied. No reason given. Just denied.
The doctor submitted a request for review, and she requested the review be expedited. An “expedited” review can take 30 days. That request was faxed to the insurer last week.
This morning I received a phone call from the doc’s office. In order for the insurer to consider the appeal, I needed to go in and sign a release form authorizing disclosure of my protected health information. (I expect this restarts my 30-day expedited review period.) Here’s what it says, in part:
I understand that if the person or entity that receives the information requested is not covered by federal or state privacy laws, the information described above may be redisclosed and will no longer be protected by law.
In other words, there is NO PROTECTION, because if they don’t take care of my information, anyone could get it. Then they absolve themselves. Too bad for me.
Another interesting item was that requests for review must be received within 180 days of notification of their “adverse decision.” Which one? The initial one when I tried to fill the script in the first place?? If so, you could (in theory) easily go 180 days just playing their try-and-fail game. And if that last attempt is more than 180 days out, you’re screwed.
While we wait for a decision, my doctor wrote a prescription for codeine, which the insurance covers. Because it’s much
better and safer cheaper to take a narcotic for pain than something that’s non-addictive.
Am I frustrated? You bet. And part of my frustration is not for me, but for people who are fighting their insurance companies every day for coverage of necessary health care. We have a close relative whose treatment is not covered at all, but is paid out-of-pocket.
There are solutions to this merry-go-round, but they will require broad agreement and not a piecemeal approach. Unfortunately our current government is a failure and can’t agree on the most fundamental things, much less complex problems like paying for health care.
[Note, please don’t tell me about your migraine solutions and how if I just do things differently, I’ll get relief. I’m sure you mean well, but I’m not looking for that kind of help.]