The never-ending, never-knowing state of “denied” drug coverage. Part 2

First part here.

I called the Baqsimi savings card program to find out how to activate the card. They said you don’t need to activate this card. They also said my local pharmacy needs to call them so they can transfer some information and then I will be able to get my free first product. Okay….

Off I went again to my local pharmacy. I relayed this information and gave them the sacred telephone number they needed to call to make this magic work. They called. Long story short: I am not entitled to this savings (Baqsimi for free, link in first part) because I have Medicare. First big let down, confusion, inaccuracy, bias against old people, you pick.

I asked my pharmacy what would a two pack of Baqsimi would cost under my Medicare coverage. Answer: $270. The reason this is interesting is because when I was on the phone with Medicare questioning the “sort of, but not, denial letter,” (I refer you to the first part of this story as linked in the first line), I also asked them what will it cost me as they’ve approved coverage. They said it would cost me $221 for one bottle and $442 for the two pack. Yes, almost twice as much as what my pharmacy quoted me and I paid. I guess I’ll know tomorrow if that’s accurate when I pick it up.

Moral of the story: There is none. Our healthcare system is broken. When I related all this to the husband, he laughed like a hyena and said, “They want you to suffer!” (pharma, the health insurance companies). At least he got some good happy hormones flowing.

So with no moral I’ll just offer this advice. Do everything in 3s: Research online, research by asking your friends, research by scanning sites. Ask a company rep, then ask another company rep, then ask your pharmacy. If your claim is denied, appeal, appeal, appeal.

I’ve read it too many times – health insurance companies deny everything today expecting people not to bother to appeal, but those who do very often get what they fight for. It’s not a happy story, this is not the world I want to live in, but it’s the only way I know to work within the system.

Note: I sent these two posts to my wonderful endo and he replied, “Thanks for sending… sorry to find this outcome. The challenge with CMS and Medicare is that they are typically about 3-5 years behind the current with regards to coverage etc. If I were to write an “off shoot” article from yours, it would be about how I call the “physician appeal line“ and get re-routed 5 times between people telling me it’s not in their department’s job to handle what it is I’m asking for. Finally, I end up with the same person I started with and try to channel all of the calmness I have stored, while listening to on hold music. Or, what’s worse, is having written an appeal letter that has literature citations and a detailed list of reasons why a patient needs X drug or Y device, it being made abundantly clear during the peer to peer ( MD to MD ) phone review and find no one has read my letter. The world we live in … and yet, nevertheless, she persisted.”

Conclusion: Healthcare is also broken for health professionals. Finding a good one is half the battle, especially when they battle for and with you, realizing they too find a powerful force aimed at deferring them.

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