Health Insurance Employee Apologizes

[lame54]

http://crooksandliars.com/susie-madrak/insurance-company-employee-apologizes

From C&L:

I found this in the comments over at Corrente and wanted to share it: http://www.correntewire.com/our_uniquely_american_health_system_revisited#comment-152259

Insurance companies reserve the right to make changes to their formularies at any time, but are supposed to notify you and allow you one month's supply of your current drug in order to give your medical provider the opportunity to "pre-authorize" your access to said drug. Your doctor cannot simply write a letter saying "I'm the doctor by god, and I want the patient to have this drug". No, he must provide evidence that he has "stepped" you. Stepped means that he/she has tried you on "approved" A, B and C drugs to little or bad results first.

Now, A and C may no longer be on the formulary, so they don't count, so he/she has to find out what approved drugs are on the formulary so that he/she can say that they have been tried and if that is true, or he/she will say it is true, then it will go to the Pre-Authorization department.

If the PA department can't sort it, say because your diagnosis does not fit neatly into what the insurance company says the drug can be used for, albeit that it works for what ails you, the application goes to the in-house pharmacist. The in-house pharmacist (average salary $90,000 per annum) will make the final decision based on following company guidelines and keeping his/her job. If the decision is that you get the drug, then said drug will be approved for you as "off formulary", moved to class 3 and if your co-pay was $25.00, it will now be $60.00 or more.

If the drug is not approved, then you will be properly stepped with the ineffective, approved drugs before your pre-authorization can be reconsidered. After you have been stepped, the drug will still be off formulary and the co-pay will still be increased. It sucks and I am so sorry.

Signed Anguished in the PA Department - United Health Insurance Inc

[barbtries]

1. "It sucks and I am so sorry."

fucking unreal the hoops they put us all through. aargh

[PA Democrat]

2. When my husband was diagnosed with high blood pressure

he tried about 4 different medications before finding one that worked without significant side effects. Then the fun began.

The insurance company said the drug that he and his doctor decided was the best to treat his BP wasn't on the insurance company's formulary. The doctor is a family friend and immediately helped us file the appeal. The insurance company took 4 months to finally approve the drug but would not cover the expenses retroactively. We were stuck with several hundred dollars in bills.

A year later the prescription expires and the doctor writes a new script for the same drug since it continues to work well. Guess what? The insurance company denies payment and tells us we have to go through the appeal process all over again.

It's a profitable scam that the insurance company uses to regularly deny coverage of needed prescriptions for 4 months of every single year.

[unapatriciated]

3. went through the same thing for ten years regarding my son's meds.

In the early 90's my son was first diagnosed with Dermatomyositis. I had a ten year battle with my Insurance Company regarding his meds. Cyclorsporin and Methotrexate. Since my sons illness is very rare some medications didn't meet their formulary. Prednisone was the standard drug of choice, most insurance doctors had never heard of the illness yet they second guessed my son's doctor on a regular basis. In my son's case prednisone was not enough. You have no choice but to pay for medication until you get it approved or 'off formulary' which is a higher co-pay. You finally get them approved for 'off formulary' than they hit you with generics and you start the procedure all over again.

[lame54]

4. .