Has anyone ever submitted an appeal to their medical insurance

[malta blue]

company and actually won?

My insurance will change effective 1/1/09 and from now on, my medication is $75 for a 30 day supply because it is not a "preferred" drug. The FDA approves only 2 drugs for fibromyalgia (Lyrica and Cymbalta). My doctor said they should be ethically bound to make one of them a lower tier group to assist people. I called the insurance company and they told me I would have to file an appeal to get my medication at a lower tiered rate ($20 or $35 for a 30 day supply)

Has anyone ever done this?

[TZ]

1. Yep. In the process of doing it again actually

My interferon is NOT FDA approved for treatment of my disease (there is TONS of scientific literature on it and its being studied in clinical trials along with a lot of people being on it from specialists)..its FDA approved for treatment of Hepatitus C.
Therefore its experimental. I had the Mayo people submit all sorts of research and thats how I won approval the first time..I'm fighting again because apparantly it was only a temporary approval. Well I have the goddamned proof in my hand tonight that it did help me and that I need to go back on it..I just need to get the Mayo people to resubmit an application for me..Thats what you really need is to get your doctor to help you with this....

[malta blue]

2. My doctor said he would fight for me.

I suppose that is the first step.

:hug:

[TZ]

3. Yes.

You can probably win but its going to take some time...At least a month to judge by my experience....

[malta blue]

4. thanks for your input

I hope your situation is resolved soon.

[KitchenWitch]

5. I am sorry you have to go to battle on this one.

I am actually surprised that I did not have to fight to have my hysterectomy last week. Granted, I had undergone an endometrial ablation two years ago which only solved my problems temporarily. And since I am under 50, they really do not want to do hysterectomies unless medically necessary. I must have proved via my doctor that it was.

[malta blue]

9. Bless your doc for looking out for you!

:hug:

[LeftyMom]

6. My nurse practitioner took care of it for me.

The birth control med I needed (due to allergies my options were very limited) wasn't on formulary. She got on the phone with the insurance people, explained that none of the approved drugs would do, and had me approved in 10 minutes.

[malta blue]

8. it's crazy that one has to fight for the medication!

The insurance company should not dictate what medication one should take.

I checked out the list and all the Ortho birth control pills are tier 3 too - that means $75 a month to be on the pill. :nuke:

[LeftyMom]

11. Do they even cost that much out-of-pocket?

Geez.

[malta blue]

12. I don't think so.

The Ortho line is not a "preferred" drug. WTF does that mean anyway? I really, really hate this.

[LeftyMom]

16. "The cheapest possible drugs in that category" is what it means.

My birth control prescription was a problem because it's all of $45/mo, instead of whatever generic birth control pills cost.

But they'd have covered a $10K labor and delivery no questions asked. :eyes:

[malta blue]

17. the Cymbalta is $145 for 30 days without coverage.

With coverage it is $75. When I spoke to the rep from the new insurance company, he told me to ask my doctor about a "drug cocktail" :wow:

These people really fucking suck.

[LeftyMom]

18. Don't you love it when insurance companies decide to practice medicine?

:eyes:

[malta blue]

20. I swear - the healthcare system just has to change.

My doctor told me that Walmart will be the wave of the future as far as healthcare because of the new flat rate clinics and $4 prescriptions. He thinks the gov't will never give us universal healthcare. It really sucks.

[TZ]

23. Which will suck ass for people like me....

That have exotic conditions with exotic treatments! Lets see the insurance company can either suck it up for a $2,000 script or pay for the results of me being hospitalized with a stroke! :grr: (my hem was very worried about me today told me I need to go back on interferon because my bloodwork is starting to "stress him out"...)

[malta blue]

25. but the insurace companies promote "preventative care"

don't they? :sarcasm:

I pray they get you the medication you need very soon. :hug:

Just what you have said about your condition and your docs "stresses" me out. :scared:

[MrCoffee]

7. Yes, and I kicked their slimy asses

Not for prescriptions, but they tried to job us when BabyCoffee was born. I nailed their butts to the wall.

[malta blue]

10. This new insurance is extremely expensive for us the employees

and the coverage is less than what we currently have.

Good for you for nailing them. :thumbsup:

[Crazy Dave]

13. As little as 15 years ago it was less than $30 a week to cover my entire family

And it was good insurance too. Now it was just under $500 a month for my wife and I until recently I had to drop mine due to no work. The county and the state say I make too much on unemployment to qualify for their government funded health insurance programs.

[malta blue]

15. I will be paying $150 biweekly for Little MB and myself.

And then there are the deductibles and the tiered prescriptions.

I tried to enroll Little MB in the SCHP program, and they said that I would be paying the maximum ($20 monthly - no biggie) BUT, I would have to let her be uninsured for at least 6 months to be considered. I cannot have my kid be without insurance, so I pay and pay....

[Midlodemocrat]

22. Jeez. That's a lot. I'm sorry.

I'm almost embarrassed that we have such good coverage. Until I add up the cost of his two surgeries and four hospital stays.

We're almost at $1,000,000. :wow:

And, the weird thing? I work in the non profit world and he works in pharma. My insurance is light years ahead of his. Go figure.

[malta blue]

24. Everyone should have good coverage dammit!

I know I am preaching to the choir, but it seems that this country should be able to get this healthcare thing settled once and for all.

[Midlodemocrat]

26. Want to hear the worst part? Prepare yourself.

*I* don't pay a dime for my coverage. We pay approximately $150 a month pre-tax for Mr.'s. And, in all honesty, if that is the insurance we had to go with, it would still be damned good insurance.

It's criminal what people in this country have to endure. I consider myself so incredibly privileged, but why? Because I was born to white middle class parents? Because I'm straight?

This election has driven some stuff right into my soul. The racism, the gay bashing. I am just sickened by it.

Sorry to hijack your thread, love.

[malta blue]

27. you didn't hijack anything

:hug:

Like you, I find all the racism and homophobia just abhorrent. I really don't understand what causes people to engage in such discriminatory practices, all the while touting their religion. It is truly a sad day for anyone who considers themself to be a christian.

Oh - and get this - after the HR sent out the costs for the new insurance plans, they actually had the cojones to encourage parents to look into the SCHP plan! I almost wrote them back that our kids would have to endure 6 months of being uninsured to even be considered. It says A LOT for them to send that email...they know we are underpaid, and they know the insurance sucks. But no one is going to fight for the little peon.

[MrCoffee]

14. The appeal process sucks, but just keep plugging away

It should be a crime what insurance companies do to us every single day. Hang in there!

[Midlodemocrat]

28. I agree. When I was having children, prior to the whole intertubes

thing, which, by the way, sucks, I got different answers everytime I talked to anyone.

[Midlodemocrat]

19. Yes. In fact, I picked up medications for Mr. and BoyMidlo

Monday night and the amount was $200 more than it should have been. I had them re-run it, what do you know? $40 for both. :eyes:

[malta blue]

21. they tried to cheat you eh?

:mad: