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.