This is what is happening to my friend Pauline in the US, in her own words. That makes it the first guest post!
AHHH...the insurance debacle.
I got a call today from the CareSource guy who manages my case and he said they denied the Prevacid again. Well, I lost it, for me anyway, then felt guilty afterwards.
AHHH...the insurance debacle.
I got a call today from the CareSource guy who manages my case and he said they denied the Prevacid again. Well, I lost it, for me anyway, then felt guilty afterwards.
Why did they deny it? Did they get the doctors letter? Did they read it?
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The reasons they state for not approving Prevacid are that the generic is the same drug as the brand name and a step program of trying other drugs is needed. Now I am on the 90 day trial of the 2nd manufacturer, but it upset my stomach on day one, so am not taking anything for my acid reflux. I'm just sitting till my waiting period has expired and so I am wasting money by not taking the same medication that I tried in 2007 when it did not work.
This is what I need to do again:
I need to use drugs from two different generic manufacturers again.
The Doctor needs to send the chart and history (he has done that).
He has written a letter. All the things they need, we've done. I asked, doesn't Caresource read anything? They're sending me the same denial letter over and over again! The two other med manufacturers are Dr Ruddy and Sandcrest. Does the insurance company read anything or do they just deny and put everyone off? I think they don't care about the people - just about making money. This will be my third letter stating the same reasons!
Sometimes it's like a merry-go-round
The rep said well, I wouldn't say they just worry about the cost not the people. I said "Well, what does this look like? I don't mean to take it out on you but this has been ongoing for about 9 months or more. I'm not taking any acid reflux meds and probably developing ulcers because of the stress".
The reasons they state for not approving Prevacid are that the generic is the same drug as the brand name and a step program of trying other drugs is needed. Now I am on the 90 day trial of the 2nd manufacturer, but it upset my stomach on day one, so am not taking anything for my acid reflux. I'm just sitting till my waiting period has expired and so I am wasting money by not taking the same medication that I tried in 2007 when it did not work.
This is what I need to do again:
I need to use drugs from two different generic manufacturers again.
The Doctor needs to send the chart and history (he has done that).
He has written a letter. All the things they need, we've done. I asked, doesn't Caresource read anything? They're sending me the same denial letter over and over again! The two other med manufacturers are Dr Ruddy and Sandcrest. Does the insurance company read anything or do they just deny and put everyone off? I think they don't care about the people - just about making money. This will be my third letter stating the same reasons!
The rep said well, I wouldn't say they just worry about the cost not the people. I said "Well, what does this look like? I don't mean to take it out on you but this has been ongoing for about 9 months or more. I'm not taking any acid reflux meds and probably developing ulcers because of the stress".
They just want us to give up on getting this med and I'm sure the majority of patients do. And if the generic made me feel okay, I'd take it but....my tummy says no way.
My CareSource Navigator said that if I get this approved, make sure
that the Dr pre authorizes it..because prevacid and nexium are the two
hardest to get. They're the most expensive.
The pulmonologist said we (patients) should all rally against this. How do you do that? There's so much to rally against...what do you start with? Doctors that drop you, meds they prescribe for you that are denied, moving your scheduled appointments to another later date, going to only the poorer hospital, switching your generic meds constantly...with different manufacturers? Is that safe?
So, what do I do now? He said to call the doctor's office: they got a copy of this denial letter and have them call the Peer to Peer group in the CVS Pharmacy. HMMMM..can I call the Peer to Peer group myself? Nope. Lucky for them. He said they aren't even allowed to call them anymore. Sherry at Dr X's office has to call so I called and left her a message. No hurry..wonder when she will start blocking my caller id. LOL
I feel bad being kind of nasty with the rep but it rubbed me the wrong way. Even Dr X said, this letter is all we can do..the last step. I hope it works. Anyone need some nails cause I've been spitting them out since 10 am?
I think (KNOW) now that I am fighting for principle. I could easily change to something else but I know prevacid doesn't upset the stomach like the others...so why try number 3, 4 and 5?
Really, I thought..according to the insurance and medical companies, that the generics are all made the same as the name brand. So???
Generic is not the same .. I don't care what they say. Its a nightmare here to get your name brand meds. I don't think the generics are made to match the name brand. For sure the fillers and delivery system may be different and probably made in factories with poorer quality control. Look at the Ranbaxy settlement for one example of substandard drugs.
It's stupid. My care source navigator told me that she tells her patients if they get do get approval on nexium or prevacid...never let it drop cause it's like gold. What a waste of time, paperwork, medication and my health. My husband used to call this "thinning the herd".
I have 2 friends who have had success on this name brand drug and no luck with the generics. I wonder if they are the only ones? It's too bad that so many with RA need to take additional drugs to protect their stomachs from damage by NSAIDS.
Generic is not the same .. I don't care what they say. Its a nightmare here to get your name brand meds. I don't think the generics are made to match the name brand. For sure the fillers and delivery system may be different and probably made in factories with poorer quality control. Look at the Ranbaxy settlement for one example of substandard drugs.
It's stupid. My care source navigator told me that she tells her patients if they get do get approval on nexium or prevacid...never let it drop cause it's like gold. What a waste of time, paperwork, medication and my health. My husband used to call this "thinning the herd".
I have 2 friends who have had success on this name brand drug and no luck with the generics. I wonder if they are the only ones? It's too bad that so many with RA need to take additional drugs to protect their stomachs from damage by NSAIDS.
I had a similar problem years ago with Celebrex - the insurance company basically ignored the rheumy's letter so I ended up writing them a letter myself stating each NSAID that I had tried, doctor's name, time period & side effects of each one (about 10 different drugs including over-the counter). Within 10 days, I received a letter from my insurance company telling me that they had approved the Celebrex.
ReplyDeleteUnfortunately, I could not get the same results on name-brand Plaquenil so I order the name-brand Plaquenil from a Canadian pharmacy (and it's less money than my US co-pay would be!)
BeckyJo in WA state
There are always some people for whom the generic drugs don't have the same effect as the name brand. It's so frustrating when you're one of them. It's good that you have a solution even though it is unsatisfying.
DeleteI do take a lot of generics myself but only recently have I found one that works poorly for me and that is Salagen. The generic was just introduced in Canada and the normal side effects are magnified to a large degree. I wonder if everyone would find the same results? I have taken the name brand for years and the generic has a dramatic effect all at once, rather than gradually which is different.
I am having to pay full price for Plaquenil. Thanks for the post on this subject. I know that I will have a paper battle ahead of me. I'm just not sure I have the energy for a fight. The Canadian thing is sounding like the only option until I have the energy to follow through with the paper/phone call war. Why wasn't this something Obamacare could have included?
ReplyDeleteIt's too bad that you have such a fight on your hands for this issue. Ironically Pauline got a call from the doctor the same day the post came out and she finally has approval for the Prevacid.
DeleteIt's shocking how much power the insurance companies have when their policies trump the doctor's orders.
Unbelievable. I'm so sorry you have to go through this. I don't have any particular helpful things to solve your insurance problem, but… Because of RA meds, my stomach is a rack. My naturopath gave me acidophilus for something else and it did wonders for my acid, too. Get the good stuff from the health food store, the one you keep in the fridge. DDS from Innovte is good. It might help while you do battle.
ReplyDelete