Strap In It’s about to get bumpy I think.
A few weeks back on another post a few of us were discussing some things we had noticed had happened to us since the beginning of the New Year. I was talking about a prescription problem I ran into. I also had something happen Tuesday kinda weird. So let me do some splaining, and either this is a sign of things to come, or my insurance Co. are a bunch of dopes.
This might hurt.
First off I’m in a Medicare Advantage plan. I know there have been cuts to them so like I said I’m not sure, but I think this could be part of skippycare and things to come. Also I have been on these plans for about 5-6 years. This Ins. Co. Has been real good to me. They have allowed me to go out of network twice. Approvals for MRI’s and things were usually in a few days. That is until this year.
Problem 1 ) short version. Denied a RX 2 weeks ago and still trying to fix problem. Skip to 2 unless you want details. :)
Problem 1) Oct – Dec 2013 I filled a Non-Prefered Generic Tier 2 in my plan which is a $0 co-pay. We used Generic because I was in Donut hole. I filled it no problem.
In Jan. 2014 Dr. Put me on Name brand to try. It is like $ 500 bucks (I did not know) It is a Tier 5 Brand Name. $ 55 C0-Pay. I filled that no problem, and then The Ins co. sent me a cranky letter saying basically to find a generic. OK.
No problem, I was on the generic and so I thought (That’s always trouble) I’ll just go back to that. I went to fill in Feb. and it was denied saying I needed a Prior Authorization. Hmm, Called Ins Co. and could not get a straight answer. Maybe 3 days to approve. They were sending some forms to my Dr. and they were to send them back to fix it. I need this med and could not wait so I paid cash for it. $ 272.00 Ughh.
Anyway back on the farm I thought this was handled till I received a new letter from Ins Co. saying I was being denied this med because my Dr. never sent in whatever. ( I know, stay with me here. ) Ughh. I Call Dr. and nurse says she needs a denial from Pharmacy for her to complete the form that Ins co. sent.
It get’s good here
I call pharmacy and ask her to send a denial to my Dr.. She says no prob, and hold on. She comes back on and says I just ran it thru again and it went thru. HUH!! Say what? It cleared the Ins.co and I could come in for a refund of my $ 272 Which I ran like a thief in the night and collected and did not pass go.
Not done (Sorry) Something is not right, so I call Ins. Co and say what’s up with this? She could see it went thru, but it still says I need a P.Auth, and it’s still in denial . So she says she don’t know why it went thru, but basically I am still denied a med that I have taken for 3 months and now they have just paid for a 4th. In March she said it will come up as needing a P A again. I just dropped the denial letter off at my Dr. and the nurse said she will file an appeal from that and hopefully it should work. Keep ya posted.
OK, did that wear your brain out? Sorry.
Problem 2
On Tues 2-18 this week I had a diagnostic test done on my back. I was sedated and they then jammed 6 needles into nerves in my lower back. I was told it would be extremely painful. That did not have any bearing on me or any decision to make. I mean I showed up and did what I was told to do. Lie down and shut up and go night night. In fact I was put into a “Twilight” sleep. I was told that I kinda screamed from the pain (Don’t remember) and they jacked me with some more juice to go night night. So I get home Tues after the procedure and in the mail is a letter from Ins. Co. saying my Injections are approved, but the Anesthesia is denied. HUH!!
A little late for that don’t you think? Sheesh! I spoke with Dr’s office and the Nurse said they are starting to get these almost routinely. She also said…
The theory goes something like this..If a woman can have a baby, you can endure the shot’s without being put out.
I don’t know if she was making this up, or it’s something she heard from Ins. Co. Bottom line is now they will have to fight this denial letter. I might have too also. I was a little ticked off talking to this nurse. I mean I was not told I may be on the hook for Anesthesia. She said they did not receive it , but it was a chance. They should have let me know. No way in hell am I paying for something I was not told about.
This test was a success, so they have just sent in for Authorization for 2 more procedures. Because they said this one you must be sedated for. This time they will sedate me again and cauterize the nerves on right side the first time and left a week later. I’m waiting to see if these will be approved or do I have to give birth first, which I know no man can. :(
Bottom Line this is the first problem ever for me. The pharmacist says this is starting to happen all the time. The Nurse at my Dr’s office said in 7 yrs she’s been there she has never seen so many denials. Everything is becoming a fight.
I would say if you have anything you have been putting off to maybe see about it sooner rather than later. I think this is about to get real bad.
~Steve~
