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Title: Jonny, Your boot is needed! Post by CarrieBethRN on Aug 5th, 2004, 6:54pm Just went to the pharmacy to get my Amerge prescription filled. Last month when I brought my doctor's prescription for 18 pills to the pharmacy, they said my insurance would only allow 9 pills for $35 copay. So I got it prior authorized, and they allowed me to get the other 9 pills for an additional $35. Today I go and the pharmacist gives me 9 pills. I say something to him, and he runs it through again and says that Aetna is rejecting me from getting the rest of the script. I asked him about the prior authorization, and he said that usually it is good for 6 months to a year. Soooooooooooo then he tells me that I have to go through my doctor's office and if I get it prior authorized within 2 weeks, he can give me the other half of the script. I NOW UNDERSTAND WHY PEOPLE PERFORM CRIMINAL ACTS AGAINST INSURANCE COMPANIES!! (Sorry for the yelling...) I am soooooooooooooo f-ing sick of this bullshit!! They are closed for the day, but tomorrow I am calling and I will be nice and patient for about 10 seconds and then I am going to rip into somebody at the insurance company...I really don't care who it is at this point!! I will also be drafting an extensive letter regarding all of the problems they have caused of late, and I will inform them that I will be giving them a bad recommendation to every single person I run into! So yeah...I'm sorry. I know this is 2 vents in 2 days all regarding insurance, but if I don't get this out...I'm going to explode. I better go check my blood pressure LMAO. <sigh> Thanks for listening.... Carrie |
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Title: Re: Jonny, Your boot is needed! Post by BlueMeanie on Aug 5th, 2004, 7:05pm Sorry to hear Carrie. That's how my insurance works too. 9 pills a month is all they allow. I guess insurance companies are smarter than the doctors you know. PFDAN |
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Title: Re: Jonny, Your boot is needed! Post by Jimi on Aug 5th, 2004, 7:05pm Someone posted a link to a Migraine site a couple of months ago about a woman who hired an attorney from Florida who specialized in this very thing. The first denial stated that AMA had claimed that taking more than 6 or 9, I can't remember, triptans per month was dangerous. The atty provided a letter from AMA stating that was not so. The second denial then was that it was the Ins. Providers decision not to pay for more than 6 per month no matter what amount the doctor had prescribed. The atty threatened to sue them for practicing medicine without a license. The third denial was that their Physician was denying a need for more than 6 per month. The atty threatened to file a lawsuit for making a diagnosis without seeing the patient, another violation. Long story short, the insurance company backed down and the patient got all the triptans the doctor prescribed. Does anyone else remember that link? |
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Title: Re: Jonny, Your boot is needed! Post by CarrieBethRN on Aug 5th, 2004, 7:11pm OK Jimi here ya go :) http://headaches.about.com/library/weekly/aa-bc-error-a.htm http://headaches.about.com/library/weekly/aa-bc-noreply-a.htm http://headaches.about.com/library/weekly/aa-bc-trip-limits-a.htm Going to send Teri an email in a minute to see if she can help me with this one. She offered to a few months ago when I was battling the exact same problem with a different insurance. Carrie :) |
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Title: Re: Jonny, Your boot is needed! Post by floridian on Aug 5th, 2004, 7:18pm Quote:
I think the lady doing the suing was a lawyer herself. I found it kind of surprising that someone was able to sue - HMOs are protected from most liability, and without the prospect of penalties, lawyers won't take a case on commission. If you have to pay $5000 in legal fees just to get your imitrex prescription filled, the insurance companies are sitting in a position to deny lots of people what they need. "Watcha gonna do? Sue me? Go ahead. Muhwahaha!" |
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Title: Re: Jonny, Your boot is needed! Post by CarrieBethRN on Aug 5th, 2004, 7:22pm I got a lawyer who is a former CH'er at that and my dad's best friend. I'll ask him what I should do and if he can help. ;;D Ready to FIGHT!!! Carrie |
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Title: Re: Jonny, Your boot is needed! Post by Jimi on Aug 5th, 2004, 7:25pm Go girl. You will never know if you don't try! [smiley=bash.gif] |
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Title: Re: Jonny, Your boot is needed! Post by alleyoop on Aug 5th, 2004, 7:34pm Hi Carrie, Sorry to hear about all your problems with the insurance. I have been down that road too. I don't know if it will helpk, but I'll relate what happened to me. Different insurance co.(BC/BS), different Dr. I am chronic and my neuro was prescribing Imitrex injects. As you probably know they come two to a pack. He wrote the scripts for 30 per mo. When I tried to fill them, BC/BS would only pay for 2 packs(4 inj.) per mo. Thankfully, my doc kept me stocked with samples to make up for it. Anyway, the next visit I had with him, I asked if he would write the insurance co. and ask them to allow more. He agreed and did. He sent me a copy lf the letter that he sent to BC/BS. He explained the serious nature of CH, citing the 15% mortality rate and telling them that this was the one drug that I responded well to. In so many words, he put the liability on them. It didn't happen overnight. It took several months, but when BC/BS did respond, they did it big time. The first time after that that I went to the pharmacy, for a $10 co-pay, I brought home a grocery sack slap full of Imitrex refills. From then on until I lost my job and insurance, I got 30 refills(60 inj.) per mo. What I'm trying to say is if you can get your Dr. to write a letter to Aetna worded in such a way that they fear a law suit, I believe you'll get the Rx in the quantities you need from then on. It wouldn't hurt to try. Just be patient, it'll probably take a while. If you decide to try it, let me know- I can probably dig up the letter that my doc sent. Good Luck.............................................. ........................................................alley ;) |
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Title: Re: Jonny, Your boot is needed! Post by Jimi on Aug 5th, 2004, 7:37pm I love this family! [smiley=bigguns.gif] |
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Title: Re: Jonny, Your boot is needed! Post by Jonny on Aug 5th, 2004, 8:01pm Carrie, PM me how much you need and I'll send it. Damn shame the fucks fuck with us!!!!! ....................................jonny |
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Title: Re: Jonny, Your boot is needed! Post by alleyoop on Aug 5th, 2004, 9:01pm on 08/05/04 at 20:01:51, Jonny wrote:
Jonny, You Are the King!!!! [smiley=bow.gif] Carrie, if you still want to try the letter from the Dr. for a long term solution, just PM me. .....................................................alley |
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Title: Re: Jonny, Your boot is needed! Post by UN_SOLVED on Aug 5th, 2004, 9:45pm on 08/05/04 at 19:34:04, alleyoop wrote:
15% mortality rate ?? for what ?? on 08/05/04 at 19:34:04, alleyoop wrote:
I'd STILL need more :-/ Unsolved |
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Title: Re: Jonny, Your boot is needed! Post by Rock_Lobster on Aug 5th, 2004, 9:55pm You are learning a fact of life... Aetna blows. |
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Title: Re: Jonny, Your boot is needed! Post by IndianaJohn on Aug 5th, 2004, 10:01pm All the insurance companies suck! The play bean counter while we suffer. Bastards! |
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Title: Re: Jonny, Your boot is needed! Post by saintslair on Aug 5th, 2004, 10:14pm Hi Carrie, Sorry to hear your having difficulties with the insurance. you may want to try to contact Glazo-Smith-Kline's Reimbursement center. They helped me get my insurance company to increase the number of imitrex meds I could get during one month. Amerge is a GSK product so it may work for you. Call 1-800-745-2967 and select option 4. Tell them your insurance company won't give you what you need and ask if they can help. They increased my imitrex to 25 a month. They will contact your insurance compnay and go to bat for you. At least they did for me. It did take about 3 weeks but it was worth the phone calls and the wait. Take care, wishing you PFNAD. Good luck, Andy |
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Title: Re: Jonny, Your boot is needed! Post by alleyoop on Aug 5th, 2004, 10:16pm on 08/05/04 at 21:45:30, UN_SOLVED wrote:
15% mortality rate for CH (suicide) 30 refills@mo=60 inj.@mo=180 inj.@mo with Q-tip But yea Mike, I realize that probably wouldn't hold you, you poor ba*ta#d. I'll bet it would get you through most of the month though! .....................................................alley ;;D |
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Title: Re: Jonny, Your boot is needed! Post by farmboy on Aug 5th, 2004, 10:18pm yes that is for sure. i wish i had a magic wand and could give everyone of then at the ins co. what we have right in mid cycle. see how they would like that shit going on every 2.5 to 3 hours for a few days straight. |
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Title: Re: Jonny, Your boot is needed! Post by Ree on Aug 5th, 2004, 10:24pm this very thing is such a bummer... We have had times when the insurance covers it and times when it doesnt... It is better if Daves cycle hits towards the end of the year... then our deductable is usually used up... they keep changing the rules which isnt fair... It costs me 70 bucks for zomig every time I get those and I think you get like 6 in a box. ree |
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Title: Re: Jonny, Your boot is needed! Post by Charlie on Aug 6th, 2004, 12:41am You know, one of these days they're gonna deny drugs to the wrong people. Pretty soon, like the Sopranos, all the 20 to lifers caught in the RICO busts will be out of jail and on medicaid or medicare. We need some excon AARP members to send some clear "messages" to HMOs. Some heads in a few duffle bags maybe. Bastards. You have to be rich or a criminal if you're sick here. >:( Charlie |
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Title: Re: Jonny, Your boot is needed! Post by UN_SOLVED on Aug 6th, 2004, 1:06am on 08/05/04 at 22:16:24, alleyoop wrote:
That's very interesting. All my years being a clusterhead and hearing the term 'suicide headaches' ... but i've NEVER seen any kind of number or statistics that show this. Never seen any reports or documentions written about it. PS...60 injections per month would be great (if I only needed 59). At only 4 - 5 day ... I'd need at least double that. Unsolved |
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Title: Re: Jonny, Your boot is needed! Post by CarrieBethRN on Aug 6th, 2004, 1:18am Well my ultimate goal with the Amerge is to get them to prescribe 60 tabs / month and have the insurance company approve that one. I'd like to try it preventatively like the study that Dr. Volcy spoke about in Nashville. Amerge really helps me a lot, and it would be great if I could stop attacks from coming by taking the Amerge twice a day. I've been told that even the longer acting triptans can cause rebound, but in some ways I think it's kinda a toss up between what is worse...Rebound, to me, doesn't seem any worse than the constant headache I always have. I have an appointment with the nurse practitioner there on Tuesday, so I'll be asking her about it. I don't know if they will go for this idea at all because they are very rebound-phobic there, but I guess it is worth a shot! Carrie |
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Title: Re: Jonny, Your boot is needed! Post by lionsound on Aug 6th, 2004, 4:28am Go Carrie! You can do it! You deserve the meds, don't let them tell you any different. I call my ins. and the hospital on the carpet all the time. if I'm not pro active about me, who will be? Good luck! |
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Title: Re: Jonny, Your boot is needed! Post by ozzy on Aug 6th, 2004, 8:46am Carrie, I have BC/BS and a mail order prescription plan. *If* you have a mail order plan, it is well worth the try. I figured, I would try. Called them up and asked them, if it would be a problem to get a three month prescription of Imitrex NS, 60 per month, 180 total. (I didn't ask for more, because the safety sheet says, no more than 2 in 24h, didn't want to push it). They said let me check, yeah, no problem. Didn't believe them, so I checked the website. The website, didn't object. Called my Dr. He wrote the Rx, I mailed it and within a week I had my box of Trex. At the pharmacy, they always gave me shit about refills and how much my insurance allows, etc. At least 1/2 the time it was the pharmacy that had a problem with it, not the insurance... Ozzy |
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Title: Re: Jonny, Your boot is needed! Post by CarrieBethRN on Aug 6th, 2004, 11:32am Hey Ozzy, Thanks for the advice on that. I used to have that option when I was on BC/BS Personal Choice of Philadelphia. We could do 3 months at a time through Merck Medco. My Aetna HMO student insurance doesn't have that option! <g> I have a few steps that I need to take, which I hope to get in motion pretty soon. I need to call the insurance company first and foremost (today) and find out why they won't cover the full script now when they did last month with the priorauthorization. Next, if necessary I have to get the headache center to retry with the preauthorization. Then, on Tuesday I have an appointment where I am going to try to get the 60/month, and then I'll probably have to go through this whole process again!!! I feel much more ready to face it today now that I've had some time to calm down from my initial anger, so I'll see how it goes! Hopefully no more problems. :) Carrie :) |
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Title: Re: Jonny, Your boot is needed! Post by alleyoop on Aug 7th, 2004, 12:44am Carrie, sounds like you've got things in hand. Thought I'd show you a copy of the letter my neuro wrote to BC/BS anyway, in case you decide you want to use it. TO WHOM IT MAY CONCERN, I am requesting 30 Imitrex injections per month for your member, Mr. Bowling. Mr. Bowling suffers from intractable cluster headaches, the main concern is to get this gentleman the relief he needs. Cluster headaches are very difficult to treat once they become chronic and intractable. I have treated Mr. Bowling since June 25, 2001 and we have tried all the recommended first and second line treatments. Mr. Bowling reports decent relief with the Imitrex injections, although he still requires daily meds and schedule II pain relievers. I understand that “decent” relief may not explain why this costly remedy be provided for him, but in pain management we are not able to relieve a patients’ pain 100 percent. We treat to make a chronic pain condition tolerable and the patient reports with the supply of Imitrex injections his pain is tolerable and he is not stressed out about whether or not his prescription will be denied. I implore you to please reconsider your decision and allow this gentleman 30 lmitrex injections per month. The long term implications of denying him a medication which offers some relief may not be realized until it is to late to reconsider. Chronic cluster headaches do carry a low mortality rate, but this rate is higher than other chronic pain conditions. I implore you again to please reconsider, Sincerely, I left all of the names out except mine, but it should give you a good template. Mike, as you can see in his letter, the doc never mentioned a 15% mortality rate. I got that from him verbally. When I first started seeing him, he kept trying to get me to take lithium. I kept refusing. He finally told me that I had a disease with a 15% mortality rate. I asked him, "Doc, how the hell do you die from headaches?" He didn't say a word, just made a gun with his hand and stuck the barrell in his mouth. Needless to say, I got the picture and started the lithium! I have no idea if the 15% figure is correct or not, but that is what he said. .........................................alley |
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