I've been "unwell" and now I am also angry!

I have been under the weather the past two weeks. I have had a continuous headache that I can't get rid of. I hate going to doctors but decided earlier this week I needed to. Earlier in the month I had the "crud"-a head cold with terrible sinus issues. With an antibiotic prescription to heal the sinus infection, I began to feel better.

Meanwhile, I received a letter from my health insurance provider in December, indicating that a medication I have taken for fours years for acid reflux was no longer going to be covered except as a Tier 1 drug; i.e, I will pay close to full price for this prescription. They are now going to provide Nexium, a drug that up until now they would not cover. Since my other prescription, Protonix, was no longer going to be covered, my physician wrote a prescript for Nexium the beginning of January. I began taking that at the first of the month. Three days after taking, I began having headaches, cough, stomach issues, etc. All of the known side effects. So, is my continuous headache due to sinuses or Nexium? Add to this stress from my job and newly imposed deadlines that in essence helped intensify my headache. Thus I am "unwell".

So I go to the doctor on Friday for the headaches and semi-vertigo issues. After an examination and additional discussion, the Nexium is not going to be good for me and my sinuses are still infected. So new medicine and treatment for sinus and a new prescription for my old medication. Of course my physician tells me that my insurance carrier, Anthem Blue Cross, will balk at this prescription and I will have to pay a higher price but my physician will present an appeal for the old medication. Sure enough, on the way to the pharmacy after leaving the doctor's office and running home momentarily, I get a call from the pharmicist saying that the insurance company will not cover the prescription and they suggest that I try Prevacid OTC or Nexium. In case you may not know, these drugs are from the same company with similar drug composition that my system does not like. I inform the pharmacist that I was anticipating this reaction and suggestion from Anthem but my physician has determined that this is not a suitable medication for me and thus they should fill the prescription and I will have to pay the full price while I await for an appeal decision.

Let me summarize to make this long rant shorter, I picked up my gold plated prescription which has served me well for four years!!!! and paid $102 for a 30-day supply when I use to pay $60 for a 90 day supply for the same medication!!!! The "moral" of this story is that my insurance carrier can and is being bought and paid for by big pharmaceutical company. To h--- with what the need of the patient is or consideration that the other drug may be more suitable for the patient since they have been taking it for FOUR YEARS. So an appeal has been registered by my physician but from hearing about others who have had to go through this for other medication, my insurance carrier will probably say no!!! This may be my new "cause" to push as this is just not right!

Since this is a blog about sewing how do I get this to relate. Well I just have not felt like sewing with not feeling well. So last night and this AM, I just read others blogs about sewing and visited fabric sites thinking about what I would make from the lovely fabrics I was seeing.

The sinus situation is starting to improve and this afternoon I spent about 1.5 hours in my sewing room working on the Vogue jacket. My intent this evening is to watch TV with DH and tomorrow do some sewing on the jacket as the sinus situation is showing some improvement and the headache is almost gone. Still a dull ache.

If you have had a similar situation with your insurance carrier and got the issue resolved in your favor, leave a comment.

Comments

  1. Linda, I am so very sorry about this situation. I can't imagine the frustration you feel. I will be praying for a resolution to this situation and that you will start feeling better very soon!

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  2. Linda, from experience I encourage you not to take 'no' for a final answer. You can appeal and appeal and appeal and appeal again -- luckily your doctor is solidly on your side. Be sure to thank him and his staff profusely every time you talk with them about this situation...which will be often, unfortunately.

    I'm glad to hear you are feeling somewhat better, in any case.

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  3. I, too, encourage you to keep appealing. Years ago, my insurance said they wouldn't cover fertility meds (not IVF), then denied the meds. We finally got reimbursed. Same dilemmas when my disabled son was born. We got a lot more covered, but still had a sizeable portion to settle. Persistence is the remedy since they expect us to give up and go away. Good luck!

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  4. Think things are bad now, just wait until Nationalized Heath insurance is forced upon us!

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  5. Oops. I meant to say Nationalized Health Care (not insurance). And by the way, sorry you are feeling so bad.

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  6. My husband had a similar issue with his cholesterol and high blood pressure medication. They finally had found a combination that worked for him to reduce his numbers, etc. then the insurance company refused to pay for that tier. Essentially he and his dr. had to 'prove' that the medication did not work (numbers went up, etc.) so that he could appeal and go back to his old prescriptions. It took 4 months.... Hope you feel better soon and get everything straightened out!

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  7. I didn't have an appeal issue what I did was reset the amount of money going to my flexible spending account. I let insurance cover what they cover and the rest comes out of the flexible spending acct. I get a tax credit for the FSA and I try hard not to think about the fact that I am paying more for a drug and that the pharmeceutical companies are laying off workers.

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  8. Oh Linda, I'm sorry you haven't been feeling well and glad to hear that you are feeling better!

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  9. I had a similar problem with my son's Zyrtec prescription around 10 years ago. He had taken that medication for allergies for several years and then suddenly the insurance carrier (Blue Cross also) stopped covering it. Claretin and generics did not work for him. Luckily his physician was willing to work with us and petitioned Blue Cross and they finally agreed to cover Zyrtec for him. It took a couple months, but persistence did prevail. Good luck.

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  10. Thats disgusting Linda.I am an Australian doctor and am horrified by your story . Here maximum for a script of nexium is $30 but pensioners will pay only $5.00 . I would hate to have to prescribe medications according to a health fund. Please never let this happen to us. Janine

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  11. Sorry to hear-- I take Cymbalta for Fibromyalgia, and it also ran into tier issues. Apparently the doc had had just about enough of this problem with a previous patient and documented it thoroughly, and it was approved.

    I'm worried that it'll be denied this year, though, because our coverage changed. As the script is $500 versus $40, no way am I going to be able to keep taking it.

    Have your doctor try prescribing it for something other than the acid reflux, maybe? If it's an h2 blocker, I'm sure he can come up with something... Not until we documented mine as NOT an antidepressant would they give way..

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  12. I think our health system is better here in Australia - like Janine said we are covered by the government for basic health cover and prescriptions. However, we still need private health insurance for quicker service and "elective" surgery. My DD needs her wisdom teeth out and that is going to cost me $1800 just for the surgeon and we have top private health insurance!

    I hope you are feeling better now and can get back to the sewing room:)

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  13. This is really a disgusting problem. Something is really wrong with the system when the health/prescrip plans dictate the appropriate medicine. Bullshit, plain and simple.

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