Adventure (struggles) with new Health Insurance
Sort of Breaking News - I am currently unemployed. Yes, I lost my job. Now, for those fans of mine that are empathetic and compassionate don’t worry to much about me. This turn of events should probably be classified as a good thing for my mental health. Let me explain, for the last several months I would literally not look for oncoming traffic when crossing the street from the employee parking garage to the office. Often, on particularly bad days at the office, I would leave the building to get lunch with the hope of getting in some sort of car wreck. I’m not suicidal I promise, just arrogant. Having already survived something like 5 car wrecks and falling off a cliff while rock climbing, spending time at a hospital for a surgery and then home recovering doesn’t bother me. In my head recovering from a surgery is a vacation…probably should examine this thought process in another post at some other time. Plus, at this point, I think one more trauma has just as much chance of fixing me as it does of causing more damaged to my poor body.
In regards to my physical health, losing my job does present a problem. I no longer have my excellent employer based health insurance. Not a good deal for a chronic patient like me who relies on a weekly shot that retails for close to $2,000 a piece for my rheumatoid arthritis and has an expensive heart condition. Not good at all. Now through hard work, luck, family, and more luck, my life expenses, outside of my health, are cheap which means I have some savings. At the risk of sounding like I’m bragging, losing my job isn’t an immediate financial crisis, only a potential one if I’m unable to change my circumstance.
In the hopes of avoiding a financial crisis, I needed to purchase new health insurance by June 1st. As you probably have guessed, much of my present circumstance has for the last couple of weeks revolved around health insurance shopping. This has meant exploring utilizing COBRA, purchasing insurance through Your Health Idaho (Idaho’s Obamacare Health Insurance Exchange), or purchasing new health insurance directly from an insurer’s website. Using monthly premiums and lowest possible deductible as my primary criteria, purchasing directly from an insurer’s website was the best deal for me. Or so I thought.
For those of you that may not know, one of my many conditions is rheumatoid arthritis. Enbrel, a biologic (a definition for you https://www.goodrx.com/healthcare-access/medication-education/biologics-biological-drugs-examples#), is one of the most popular and generally considered “the best” medication for my illness. Of course with being “the best” comes a heavy price tag, roughly $2,000 a shot heavy. I take 1 shot every Sunday, For those of you that don’t like math, that’s $104,000 a year (my house didn’t cost this much). Needless to say, one of the first things I did after purchasing my new health insurance was to call to make sure my Enbrel would still be covered or did I need a new preauthorization (since I had them on the phone I check on my other prescriptions).
Big shock, the insurance company wanted a new preauthorization from my doctor before they would refill my prescription for Enbrel. Since the med is so expensive I have to use my insurance company’s specialized pharmacy or they won’t cover it. At this point I would like to point out that my quote “new” insurance is through the same carrier as my “old” or previous insurance. The big difference is that instead of the premiums mostly being paid by my employer, I get the honor now. Logic, at least in my brain, would dictate that all preauthorizations while under my old insurance would transfer over. After all, again in my head, if my doctor wanted me on Enbrel on Monday he is still going to want me on it on Tuesday when the new insurance started…again that is Alan logic which might be why I don’t run the world I’m starting to think.
Since I’m a highly educated and some would argue, an accomplished epatient (patient) advocate, I asked the customer service rep if any of my other meds (I have 9 other prescriptions) needed a new preauthorization. According to the customer service rep, and I quote, “it looks like your Enbrel is the only medication that the preauthorization did not transfer over.”. Cool, by almost any measure going through a new preauthorization is a waste of time and effort but Enbrel is a serious med with a ridiculous price so it does make sense in that nothing happens in our “system” without a butt load (I believe that metric comes from CMS). of paperwork. As I write this I’m still waiting to hear back from the specialized pharmacy on whether they will approve the new preauthorization or not.
HAHAHAHA, silly Alan, you know nothing is ever this simple when it comes to our healthcare system.
To help combat my rheumatoid arthritis, severe osteoarthritis pain from the trauma from my rock climbing fall, my degenerative disk disease, and many other arthritic and nerve pain conditions my pain management doctor prescribed a medication called Nucynta ER for me about 10 years ago. According to Nucynta ER’s website, this medication is “a strong prescription pain medicine that contains an opioid (narcotic) that is used to manage pain severe enough to require daily, around-the-clock, long-term treatment with an opioid when other pain treatments, such as non-opioid pain medicines or immediate-release opioid medicines, do not treat your pain well enough or you cannot tolerate them.” At the same time, my doctor also prescribed up to 4 Oxycodone’s per day to help manage my flare ups and what textbooks would define as acute pain. Although not perfect, this combo has kept me working full-time, hiking, an homeowner, an amateur photographer, and a Stanford University epatient scholar just to name a few of my accomplishments.
My old insurance paid my May refill claim of Nucynta ER and Oxy without question or incident. Since it is a narcotic, my doctor can’t prescribe refills which means I took the last pill from the May refill on the morning of June 12th. After consulting with my provider, the new June prescription was sent to Fred Meyer which I called them about the morning of the 12th. According to Fred Meyer, my insurance was not allowing them to fill it at that time for reasons they were not sure about so they suggested calling them back on Tuesday. Odd but ok. On Tuesday when I called I received an automated message stating the Nucynta ER would be ready on Thursday after 3pm. Again, odd but I thought that since I had a “new” plan that this delay was because of the change so its not worth getting worked up about, basically just accept the nonsense and live to fight another day. This acceptance changed on Thursday.
When I inquired about the Nucynta on Thursday like a good, patient, patient, Fred Meyer told me that it had been denied by my new insurance because they needed a preauthorization. WHAT?! I had an appointment at 10:45am the following day with my pain management provider so I decided to keep my temper under control at least until then.
The first question out of my providers mouth that morning was “why hadn’t I picked up my prescriptions (the Nucynta and Oxycodone) yet?”. No chronic patient should ever have to tell their doctor that they can’t pick up their prescription due to a business decision by an insurance company. However, since I don’t run the world, I immediately launched into my preauthorization nightmare story at that point. After some back and forth and checking my EHR, Juliet confirmed that the clinic had sent my new insurance all necessary records to justify the Nucynta prescription. She asked me to call the insurance company and confirm that they had received all the records they needed and try and determine their process going forward.
After speaking to a couple of customer service “partners”, my health insurance told me that the reason for denying the prescription was because I scored high on their opioid scale which they claimed put me at risk for an overdose. Since they “care” so much they wanted to make sure I was not in danger by requesting that my doctor send in preauthorization paperwork. At this point I’m going to break with my epatient advocacy training and call bullshit!
First, as a quick reminder, my insurance company approved and paid for the claim with the same opioids and dosage in May as I was wanting this month. They have been approving and paying for this combo for basically the last 10 years.
Most importantly, Nucynta is a narcotic which means a sudden and unplanned stoppage can cause harmful and dangerous (especially since I have heart issues) symptoms. Although there is no way to confirm, research shows that more than likely my severe chronic pain was the primary cause of my AFIB. My long-term pain levels have started to explode in the last few days which my Oxy is not helping with much. This means my brain fog has also exploded which makes things like driving potentially dangerous. In addition, my stomach isn’t what one would call happy and several times a day I break out in cold sweats, all signs of opioid withdrawal. All of this is being caused because my “new” insurance is trying to avoid paying for yet another expensive prescription.
Next, their opioid scale is dumb. Basically it gives every opioid a numerical value which they add up. They then look at the numerical value of addicts that have overdosed in the past and compare the 2 numbers. Now, I’m not arguing that my opioid dosage isn’t high or even dangerous. My point is that my patient story can’t be boiled down to an arthritic formula that most junior high kids could complete in their math class. Not only that, I’m a chronic pain patient due to multiple factors, comparing me to someone with an addiction illness is not fair to either one of us. No chronic pain patient’s story, or chronic patient regardless of disease, should ever be boiled down to a number at the end of of pretty simplistic formula.
While on the phone with the new insurance, they old me my doctor could label the preauthorization submission as either “normal” or “stat”. If the doctor label the request normal that meant it could take up too 14 days before I could receive a decision, stat meant a decision in 72 hours. So I called my doctor back and asked how they labeled the request. As a highly educated epatient I now feel kind of stupid for asking this. The doctor can only label a risk stat if its for a life saving medicine. Since my life isn’t technically dependent on Nucynta, they had to label the request as normal. Essentially all preauthorization requests are going to take up to 14 days, presenting me with this option is just a away for my insurance company to avoid responsibility for my increased pain and withdrawal symptoms. Basically, I could be July before I find out if I can get my Nucynta or do my doctor and I need to create a new pain management program.
At epatient advocacy training camp they like to stress the importance of not creating an adversarial situation. An us vs them attitude basically does nothing but create more us vs them conflict which is why up to this point I have avoided using the name of my health insurance. However, I’m having second thoughts about that. Blue Cross of Idaho is causing me unnecessary pain and discomfort. Their business policy as created a situation where a potential group or committee who review preauthorizations, consisting of people I’ve probably never meet anywhere in life, let alone discussed my patient story with, could significantly alter my treatment and pain management plan. This isn’t right which is why I feel its ok to call out Blue Cross of Idaho in this situation.
This story is not done. Please cross your fingers and stay tuned, I will let you know how it turns out.
