Tuesday, October 10, 2006

Insurance battles

An update about the walk will be forthcoming, but first I must rant a bit about Riley's insurance.

My husband is a teacher. We have NC State Teacher's health insurance. When given the opportunity, we switched to a PPO plan. It had what appeared to be better coverage. One of the main reasons for switching was that test strips were covered under a $10 co-pay. Period. The end. No fine print anywhere to be seen.

In the previous plan, I would pay for Riley's strips up front (400 strips= $386.00 per month), then a month or so later the insurance would send me a check for the 80% of the strips that they covered. So, we were paying around $77 a month for strips. When we saw the $10 co-pay, we just couldn't resist. There are other great things about the plan, but the test strips were really our deciding factor. This new plan costs a little bit more per month, but we end up saving money in the end, due to the decreased deductible, etc.

One downfall was that we had to give up our wonderful Freestyle meter. I really like that meter. It's so small and the test strip lights up to make middle of the night testing much easier. Under the new plan, Freestyle is not a preferred strip. So, we got a new prescription from the endo for One Touch Ultra strips. I thought I had jumped through all the hoops I had to. Giving up the Freestyle meter was a small price to pay for the savings we would be receiving. ($804.00 per year).

I walked into my local pharmacy on Thursday and handed them my brand new prescription for a 30 day supply of strips. The endo even wrote on the prescription "Small child on the pump, must test at least 12 times a day" I was feeling good. I was smiling thinking of that mere $10 I had to dish out.

Mr. Nice Pharmacy Man tells me the prescription won't go through. He said it says I need prior authorization. This is the first I've heard of such a thing. So, I call the endo and give her the 800 number I have been given so she can approve the strips. When she calls the number, she is told that my plan does not require prior authorizations for strips. So, the ball is back in my court.

I spent a little while on the phone on Friday trying to get this all straightened out. I didn't spend the whole day, however, because Friday was a special day. I was finishing up with some last minute walk things and it was Riley's one year anniversary. (We did go to the movies and saw Open Season. It was pretty funny. Ashton Kutcher is the deer and I've always thought he's hilarious.) Ok, back to the insurance saga.

By 5:30 Friday, I had gotten no where and the pharmacy closes at 6 PM. I ended up going to the pharmacy and buying 25 test strips just to get me through the weekend. I had a few Freestyles left.

I begun my quest anew on Monday morning. Then, I went to see patients. And started the quest back up on Monday afternoon. In total, I spent 3 hours of my work day on the phone with the insurance company. Everyone I talked to told me that they couldn't authorize more test strips. But, they couldn't tell who could. I was bounced back and forth from the insurance company to the people who handle the pharmacy benefits. Both sides told me they had nothing to do with test strips.

What I did find out is that the new plan would only allow 150 strips per month (or 5 per day). Yes, 5 per day. I used 5 in a little over an hour Saturday because Riley was low and didn't seem to want to come up. I had to keep testing until we got him in range again. 5 strips a day is just totally ridiculous for someone with Type 1 diabetes, especially, a small child. The insurance people did not see my point. They were absolutely no help, whatsoever.

By the end of my work day on Monday, Riley had 5 strips left. While the insurance company thinks that should last me 24 hours, they lasted until 8 AM Tuesday morning. Foreseeing that 5 would not be enough, I go back to the pharmacy. Mr. Nice Pharmacy Man gave me 100 strips on credit until I can get all of this straightened out. (By the way, Mr. Nice Pharmacy Man owns this pharmacy and was very nice to just hand me 100 strips without making me pay. He has always been very helpful and even donated $100 to Walk of Hope).

(Let me interject here, I started this post almost a week ago and am just now getting back to it. So, I'm just going to make a long story short.)

Tuesday I spent another 2 solid hours on the phone. People kept telling me that I could hang up and someone would call me back. I refused to hang up. I just kept telling them that whoever they were going to talk to I wanted to be on the phone at the same time. So, I had several 3 way conversations.

The very first person I called on Tuesday was named Heather. I told Heather all that I had been through and she asked if she could stay on the line with me. She stayed on the other end the entire 2 hours. I thought this was going above and beyond the call of duty. It was nice to have her there because when other people didn't want to listen to me, she would jump in and people would start taking me seriously again. I got her supervisor's name and will be sending an email to Medco today to let them know what a good job she did.

Ok, I said I was going to make this short. I ended up talking to one of the higher ups who gave me her direct phone number. In the end, I found out that the insurance company uses the FDA guidelines which recommend that people test 5 times a day if they are on insulin. Come on. The FDA can't even differentiate between Type 1 and Type 2 diabetes? (I spent a lot of my time on the phone educating people about Type 1 diabetes and why Riley needed to test so much.) So, my plan will allow 150 strips per month under the $10 co-pay. Then, the other 250, I have to pay up front like I did before and then wait to for insurance to send back the 90% they owe me. It is still better that it was and still ends up saving us about $400 a year, but it's not as good as I thought it was going to be.

I just kept thinking while I was on the phone, "How often will Riley battle with people like these over his lifetime, just to get what he needs to survive?"

Another injustice that comes along with this stupid disease.

21 comments:

Jamie said...

Oh Penny - that is just CRAZY! It always boggles my mind how insurance companies think ... we've had our own share of troubles with ours ...

I can't wait to hear how the walk went, though. I've been checking back religiously to read up on it!

Penny said...

Jamie,
I promise a walk post will be coming shortly. It took me over a week just to write the last post. It's been very busy around my house lately.

Anonymous said...

I am so sorry, we are going through new insurance pains as well. Hang in there. I hope the walk went great. Does hubby work at NC State? My cousin works there.
Viv

Penny said...

Vivian,
My husband is a teacher at a local high school. I thought he had great insurance (and I guess he does), but that 5 strips a day thing threw me for a loop.

The walk was great. I have revival at church this week and then I'm heading up a supper at my son's school on Thursday night, so I probably won't be able to post again until Friday. I will tell you all about the walk then.

Scott K. Johnson said...

Hey Penny!

Open Season was a pretty good movie. The kids and I liked it too!

The insurance thing really sucks, and I hate having to jump through extra hoops just to get the things I need to survive. It's so very frustrating.

How can they not understand that by paying a little up front that they will save a lot down the road?! I suppose they figure you'll be on some different plan by the time you need the big buck coverage.

Bastards.

Laura said...

grrr insurance. I dont even have it because the government says i make to much money ( minimum wage)and I also work to many freakin hours to get medical assistance. This didnt help that I was hospitalized 2 weeks ago in ICU for 3 days because i had the flu and my sugars went to 890 and was in DKA


Other then that im fine and dandy now

Penny said...

Scott,

I cannot for the life of me understand why the insurance companies won't get on the prevention bandwagon. It is soooo much cheaper to try to prevent complications than it is to treat the complications be it from diabetes, heart disease or whatever.

Plus, a Type 2 would probably get along just fine with 5 strips a day. But, my son basically has an organ that no longer works. It's just very frustrating to me that insurance companies won't differentiate between Type 1 and Type 2. They are two totally different diseases and should be treated as such.

Ah, typing this has gotten me all fired up again.

Shannon said...

Hey Penny, you're in the Join Lee Now newsletter!

If you haven't received it, I've posted a link on my blog.

Congratulations!

nicolep said...

Damn. Damn. Damn. Insurance. I can't freaking believe that.

Who runs the FDA? I think a letter writing campaign is in order. I'm pretty sure between all of us in the OC (and our familyies) - we could make some sort of point.

I could draft something up - I'm going to do some research... Would others post about it if I did?

nicolep said...

OK - so I did some research. The only "regulations" around glucose monitoring on the FDA site are here:

http://www.fda.gov/diabetes/glucose.html

Here are some quotes from this piece:

As a general rule, the American Diabetes Association (ADA) recommends that most patients with type 1 diabetes test glucose three or more times per day. Pregnant women taking insulin for gestational diabetes should test two times per day. ADA does not specify how often people with type 2 diabetes should test their glucose, but testing often helps control.

Often, self-monitoring plans direct you to test your blood sugar before meals, 2 hours after meals, at bedtime, at 3 a.m., and anytime you experience signs or symptoms. You should test more often when you change medications, when you have unusual stress or illness, or in other unusual circumstances...

Talk about being evasive... "Three or more times a day?" I'd venture a guess that the vast majority of HEALTHY diabetics fall into the "or more" category.

Also - look at that second paragraph. If I count that up - on a day when there is no abnormal occurence, that's 8 tests (before and after breakfast, lunch, dinner, at bedtime and 3am)...

What regulations is your insurance provider talking about? I know that you're probably tired of fighting, but I'd call them back and ask them to direct you to the regulations they're following. If they give you the same story - I'm willing to make a call to the FDA for you.

It's just wrong that Riley can't get what he *needs*.... What do insurance companies think we're doing - throwing testing parties with all the strips they're giving us???

Oh, I am so fired up right now.

Penny said...

Laura,
Here I am complaining that I don't get enough insurance coverage when you don't get any at all. I'm sorry.

Shannon,
Yes, that's my baby in the newsletter. I was wondering if anyone in the OC would notice. (Scott noticed too)

Nicole,
You've got me all fired up again. From following your link I can't seem to find where the FDA guidelines recommend that people on insulin test 5 times a day. Still, "people on insulin" and "people with Type 1 diabetes" are not the same thing. I have plenty of Type 2 patients that are on insulin. Cannot even the freaking FDA differentiate between Type 1 and Type 2?

I may be making a call to the FDA and get my story straight before I try to tackle the insurance company again. You know, this isn't just about Riley. It's about everyone that lives with T1 on a daily basis.

It just makes me sick!

nicolep said...

Penny -

Do call the FDA. I think the insurance company is using a line on you. Especially considering that my insurance company told me their guideline was 250 - based on some regulation (they didn't site the FDA though) - but that was overridden after numerous and LONG phone calls to them.

You are right - it's about ALL of us.

Penny said...

Nicole,
For time's sake, I have emailed the FDA regarding their recommendations for glucose testing. If I don't get a response soon, I will call them on my day off.

Penny said...

OK, pretty much every web site I've gone to encourages people with Type 1 to test 3-4 times a day. These must all be written by people who do not have Type 1.

We test Riley before each meal and snack. Then again at bedtime and at least once, usually twice in the middle of the night. This is bare minimum testing. That's a minimum of 8 times a day. But, there is usually always a need to check an extra time or two every day. I've looked back and he is tested an average of 11 times a day. Excessive? Nope. I never test unless I need to know what his sugar is for a specific reason. Like I told the insurance lady last week, "I'm not just checking his sugar for fun. As much as I wish I didn't have to do it, I do."

I see all in the media and other places complaints about people with diabetes draining the health care industry with their complications. But, no one seems to want to stand up and say how often people with D should test in order to acheive those normal A1C levels which have been proven to greatly decrease complications. It is certainly not 3-4 times a day.

OK, I'm putting my soap box back in the closet now.

Anonymous said...

Penny -

DON'T put your soapbox away - EVER. You are advocating for your child - and we all understand that. You have to keep working to make sure that the insurance company understands that too. I am interested to see what the FDA has to say. If they really recommend 3 to 5 times a day - then we should REALLY get our soapboxes out. That is just not enough testing to lead healthy life with this disease. Please let us know what they have to say.

N

Penny said...

Anon,
I have only put my soapbox away for the time being. I will persue this matter and I may ask for all of your help.
I do know that the ADA recommends that Type 1s test 3 times a day. Perhaps a letter writing campaign is in order?
Is anyone with me? If so, I can do a post with the contact information.

nicolep said...

I'd help for sure. We could probably put it up on our blogs and get other OCers to write.

Penny said...

Thank you Nicole. I may take you up on your offer soon. I called and left a message with the pharmacist that I talked to last week and asked her to clarify what she told me and to tell me where she actually got her numbers from. I haven't heard back from her yet.

nicolep said...

Any word yet?

Penny said...

Nicole,
I haven't heard anything from the FDA, the ADA, or from the pharmacist at my insurance with which I left a message. She was who told me about where they got their limit from.

I haven't given up on it yet. I'm just trying to gather up some strength for the battle.

Thanks for asking.

Nicolep said...

Absolutely, Penny. Let us know when you here. I'm interested in what they'll have to say.

H