| It is a drag but the combo of meds work, so it is just one of those things that you live with, fill your prescriptions and move on. That was until we went off of the COBRA from my old employer and on to the plan at Staples.
Liz went to refill her prescription at our pharmacy and was told they couldn't do it because the drug Dexilant, which is the generic version of Capidex had to be pre-approved. So she waited, and then ran out of this drug. Being the patient kind of person she is, she waited a whole week while her digestion went to hell. Her stomach swelled and she started having very bad constipation.
After a week she called the pharmacy and her doc and neither had heard anything from CVS. So she called them and after going to through the process of getting a person on the phone, she was told that it had been denied. That was unacceptable so she asked her doctor to appeal, which she did.
More five more days passed, Liz stopped being able to have a bowl movement at all. No word from CSV. At that point she called CIGNA who are the medical providers for her plan. They told her there was nothing they could do. She then called CVS again and was told that the appeal process had a pharmacist looking into it and that it would be at least 72 business hours before they would have a decision.
At this point I got pissed and did the Hubby thing. I spoke the Joy the Customer Service Rep. I knew that she did not have any power to say yes, so there was no point in roughing her up but I did ask if I could talk to someone in the appeals department. I wanted to put the human cost of this bureaucratic BS in front of someone who could say yes. What I was told is that not even the Customer Service Reps can talk to the Appeals Department, they can only e-mail them.
After that Liz went to the doctor who was already really pissed about this. She had been dealing with CVS from her side and thought they were "morons" about this issue. The doc was nice enough to give Liz a couple of weeks worth of samples of the drug so that she would not get an impacted bowel or worse a perforated bowel.
The doc explained (though CVS never did to Liz or I) that she has all the secondary symptoms for prescribing Dexilant but not the primary one it was developed for, which is to treat ulcers in the esophagus. Our doc told us that she told them this is what she is trying to prevent by prescribing it but CSV seems particularly dense about understanding it.
When we talked to the Joy on Sunday she said that the appeals process would take 72 business hours. When we called this morning, we were told that they had up to 30 days to decide. I got on the phone with Stephanie who was a supervisor at the call center and tried to get the truth out of her. Apparently the process for initial approval is 72 business hours and if you are denied then it is up to 30 days.
That tells me that the first process is a process to say no. It is designed to make it hard for the patient to get the drugs, even if they have been on them for years, like Liz has. I am still trying to wrap my head around the idea that someone who neither the doctor nor the patient can talk to, who does not seem to be able to read a long term medical record and has never seen the patient can make a competent medical diagnosis as to what drugs are needed. They are not seeing the fact that my wife has not had a bowel movement in days and how that is affecting her. They don't seem to be able understand the process that we went through to find the right combination of drugs that would allow this in the first place.
What adds insult to injury is that they are doing this over a generic drug. It is not a cheap generic, it would cost about $200 a month if we bought it ourselves and in the financial striaghts we are in, we just can't afford that on top of the $255 a month we are paying for insurance.
I tried to get a statement form CVS several times. I called their PR department, I asked for call backs from someone who could talk on the record and explain why they will not allow anyone to talk directly with their appeals processors and to find out if they thought it was good medical practice for someone who had never seen the patient to make medical decisions about them.
I did get Lindsay Shearer from CIGNA's PR department on the phone. She was less than happy about the idea that her company is on the hook for the medical problems that this bureaucratic BS might cause. She explained that their preferred method is that any company working with them buy the whole package of care from them, but it is not a requirement. The reason this is better is obvious, there would not be this disconnect where CVS gets to not care about the costs that not have a medication causes and can pad their bottom line at CIGNA's and the patients expense.
There is another culprit here as well. Staples in doing a penny wise, pound foolish decision to split these functions has left their employees in a real trick bag. They pay a reasonable amount for insurance, but it is insurance that does not really help them very much. Liz has already lost a day of work over this and might lose more. If the appeal is denied she is stuck with needing a drug her cheap ass pharmacy plan does not want to pay for. Then the choice is do we keep paying for the whole insurance package or try to find another $200 a month in a budget that has the house cold, the fridge bare and the creditors baying at the door?
I wish I could say I thought that we were a unique situation, but the fact is I know we are not. The ACA is a good step forward, it did not get us everything we wanted but it was and is a start. The thing is this kind of choice between health and being able to pay the heating bill is going to go on in this nation until we get to a single payer system. Corporations have a legal responsibility to try to make their shareholders as much money as possible. As long as the profit motive is in place in administrating health care we will have problems like Liz's.
I have told CVS that I intend to light them up on a regular basis over this issue, not just because they are making my wife cry (which will always get you on my shit list) but because if it is happening to Liz it is happening to a lot of other hard working people who think that having insurance is supposed to mean that you get the care you need, especially when you have been having the same care for half a decade.
The floor is yours. |
