Health Insurance

I recently did battle (5 phone calls, 10 hours, 3 letters) with my health insurance company. I did win and can continue to get my medication locally and keep all my prescriptions at the same pharmacy, which is a wise thing to do. If you find yourself in a struggle with your insurance company you will want to do several things.

1. Keep a written record of each and every phone call including day, date, time, duration, who you spoke to and what the responses were.
2. Follow up.
3. Ask for a supervisor. Write down the name and outcome of the conversation.
4. Follow up.
5. Ask for a case manager for your probelm. Write down the name and outcome of the conversation.
6. Follow up.
7. Send or fax letters and follow up.
8. Always restate the problem and offer logical solutions.

Here is my appeal letter:

I am writing to request a modification in how I receive my Cellcept specialty medication. The new required arrangement through Specialty Pharmacy has a significant change of putting my health and life in jeopardy.

I am requesting that you accept one of these three solutions:
1. Permit me to requiest a refill when my current prescription in 50% used.
2. Or permit me to purchase Cellcept out of network and file for reimbursement.
3. Or permit me to obtain a 90 day supply each time.

On Friday, March 13, 2009 I received a letter from United Healthcare dated February 27, 2009 stating that as of April 1, 2009 I would no longer be able to obtain my prescription for Cellcept from Bioscript, the last specialty pharmacy that United designated, but must instead use Prescription Solutions.

I take Cellcept for lupus nephritis. There is no cure and I will be on this medicaiton for life.

According to Prescription Solutions:

• I can receive this medication by United Parcel Service, and it must be signed for.
• I can receive this medication via United States Postal Service and it will take 7 to 14 days after the refill is called in before I will get the medication.
• I can only get a 30 day supply.
• I can only request a refill when the medication is 75% used up.

The problems are:

• I have an erratic work schedule and am rarely in the same place two days in a row, making it impossible for me to be certain that I will be present to sign for delivery of the medication. Under my HIPAA protections, I choose not to disclose my condition. Forcing me to receive my medications at the work place can easily violate this right, as regular monthly deliveries will raise questions forcing me to disclose or be dishonest with my employers. This is not an acceptable option. I live alone and my relatives all live out of state. The office in my complex refuses to accept packages for residents. Leaving it outside is dangerous because of the possiblity of theft and the brutal heat of Florida possibly reducing the efficacy of the medication which allows me to keep my own kidneys.
• If I can only request a refill 7 days before I am out of medicaiton and it takes 7 to 14 days for the medication to come through the USPS, I am at risk of being without the medication for one week of every month. Without this medicaiton, the lupus nephritis will worsen and can lead to dialysis, which is far more costly than accomodating my request.

On Friday, March 13, 2009 the representative with whom I spoke from Prescription Solutions informed me that Cellcept was only available through specialty pharmacies and that a regular pharmacy like Walgreen, Wal-Mart and CVS did not even carry it! I got my Cellcept at Walgreen for 5 years! It is unacceptable for your employees to fabricate information.

On Monday morning, March 16, 2009 I spoke with Corey (Cory?) in your Rapid Resolution who informed me that I would have to file an appeal which could take up to 30 days. I can't wait that long and said so. I was told that I could file a quick appeal verbally and that she would do that. She also said that I would be notified by telephone within 48 hours. I heard nothing on Wednesdy, so I called on Thursday, March 19, 2009.

Today Renesha tolde me that the appeal was rejected because there was no information and that a letter had been sent on March 17 to inform me of that fact. I asked why I had not received the promised phone call informing me about the status of the appeal. Renesha informed me that United does not call. Renesha told me to file a written appeal and that it would take 30 dyas. Of course, several days were already wasted because of Coy who, like the person in the pharmacy, created information that was not true.

Renesha gave me the number to which I will be faxing this appeal. She also indicated that I would have a response within 72 hours, which, given the weekend, translates into a response by the close of business on Thursday. I confirmed this with her several times.

Stress is the single biggest factor in causing systemic lupus erythematosus to flare. The fiasco in trying to resolve this issue regarding my medication has been extremely stressful and has taken hours and hours of calling. I have been told repeatedly that nothing can be done. My health insurance company, who I would like to believe has my best health and wellness at heart, particulary since doing so will minimize my used of insurance and resources, chooses instead to put me in a position of having to worry every single month about whether or not my medication will arrive and puts me in jeopardy of a lupus nephritis flare which can have grave consequences.

Please consider the three options outlined at the beginning of this letter. I look forward to your telephone response on Thursday, March 25, 2009.

[Note: They never called. First I received two rejection letters. Then a letter dated April 3 and signed by a senior pharmacist arrived informing me that I could continue to use the same pharmacy I had been using. The next month, the drug went generic!]