Annie: "Hi, I'm calling to get a seizure medication, Spykenwayv, covered for our patient Amy G'Dala for 2015."
Ms. Recite: "Certainly, let me look at her records... Has she failed the required generic medications?"
Annie: "Yes, same as last year when we went through this."
Ms. Recite: "Okay. I still have to ask, as some of our policies have changed for 2015. How long has she been on Spykenwayv?"
Annie: "Since 2010, same dose as last year.”
Ms. Recite: "And is it still working for her?"
Annie: "Yes. She's been seizure-free since she started it."
Ms. Recite: "Good. Now, for 2015 we have quantity limits of 30 pills per month on all of our tier 4 medications."
Annie: "But Spykenwayv can't be taken only once a day. It has to be twice a day because of its half-life. So she'll need 60 pills, technically 62, since most months are 31 days."
Ms. Recite: "Well, for 2015 Major Illness will only pay for 30 per month. That's the best we can do."
Annie: "Can I talk to..."
Ms. Recite: "Perhaps she could try taking it every other day? Maybe use a cheaper medication for the days between?"
Annie: "Uh, you can't do that with epilepsy medications. You have to maintain a stable blood level because..."
Ms. Recite: "Could she skip it on days when she isn't working? If she has a seizure at home would that be a big deal?"
Annie: "Yes. It would. She could have multiple seizures and end up in ER. She could die. She could injure her kids, or have a car accident."
Ms. Recite: "Since you mentioned ER, please remember that for 2015 Major Illness strongly recommends you go to one of our approved urgent care centers instead. They have convenient locations throughout the greater Grumpyville area and are staffed from 8:00 am to 6:00 pm weekdays and 9:00 am to 4:00 pm Saturdays by trained medically-affiliated professionals."
Annie: "I'd like to talk to a supervisor, please. This is an issue that seriously affects a person's life and well-being, and you're reading to me from a script."
Ms. Recite: "It may take a few days for her to get back to you. We only have one right now, and she's swamped. The other 2 both quit last week."