Thursday, March 19, 2015

Annie's desk

Ms. Recite: "Major Illness Insurance medication review, may I help you?"

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."


Bobbi said...

I'll bet they did!

Andrew said...

I wonder why!

Packer said...

Send transcript of that conversation to State Insurance Commissioner, 20/20, 60 Minutes and Drudge Repost.

Nurse Lilly said...

"Trained medically-affiliated professionals."

Does that mean the trained janitor who's affiliated by working at a medical facility is now seeing patients?

Anonymous said...

Sweet. Clothespin. Jeebus.

Next up, "Does Grandma Really Need That Replacement Pacemaker?", followed by, "Can't She Just Turn it Off On Days She Wants to Be Dead?"

I predict big box office for both.

clairesmum said...

I'd like to think that this was a parody of an actual conversation, but the realist in me knows this is closer to an actual transcript. Makes me gag when I get mailings from insurer about how much they care about my health!

Gracie's Mom said...

Once again; so glad to be Canadian!! My doctor writes the prescription, I get it filled. End of story.

You poor sods must go broke with the cost of health insurance, and then the companies lay this B.S. on you, they should be ashamed.

The Condign Gentleman said...

"They both reached their yearly limit of 26 weekly paychecks."

Anonymous said...


Ivan Ilyich said...

That's strange, because my experience with this issue is that I get 30 days of medication, regardless of how it is taken. I wonder if the person giving the information just had it wrong.

Unknown said...

Ivan Ilych, that was my thought. Pharmacist here, in Canada, and I deal with this all the time for our patients who have private insurance.

"No, we do pay for cymbalta 60mg a day, but not 30mg bid, and not any higher dose because WE have decided that WE know the best way for this to be taken.", "No we only pay for x tablets per month, regardless of how it was prescribed"

Vwey frustrating and time consuming at the pharmacy as well.

Mage said...

Sounds too real to me.

Anonymous said...

I would love to give the comment, 'surely you jest' but I surely can not. Unfortunately. And, I am a pharmacist. And, these 'nincompoops' purport to 'know' more about drugs than I do.

As a parent, not only does it make me crazy, but it makes me scream and cry and write letters to the editor, and next it will be the state attorney general. Which is sad, because I would never have believed the impact this has on mental illness, physical illness, society in general, unless I, as a parent of a patient with serious mental illness, experienced it firsthand.

Anonymous said...

That is crazy. And look at this link:

I don't know these people, I don't post there, but this thread caught my attention and it's similar to what you're posting about. Horrible.

BendySadness said...

And yet I hear some Americans mocking our NHS. It may not be perfect but at least we don't have this. Or co-pays tripling for somebody on disability (a friend of mine).

C. said...

Nah. I have a monthly pill limit too. They won't pay for 30mg 2x a day but will pay for 60mg 1x a day. So stupid.

Cass said...

Gracie's Mom - Don't be too sure. I'm Canadian, ended up with Blue Cross (an American insurance company) as my drug insurance company for a while.

They decided that every year I needed a doctor's note to prove that I didn't have cystic fibrosis (genetic disease you are born with and can't acquire). Every year. Again. And no, they wouldn't accept the genetic testing I had that proved I didn't have it. But they needed it every single year for me to get my enzymes (because they needed me to prove I didn't qualify for some government funding program, and the only way to do that was to prove I didn't have CF. WTF??) Biggest waste of time and money and taxes.

So it does happen in Canada. Just wait until the American companies realize we haven't implemented any of the protections the US got when they put in Obamacare. It'll be 10x worse than travel insurance already is.

Dr Grumpy is warning us .... beware the insurance.... beware.... it is come from the south.....

Amy said...

It explains so much. It also explains why we will never retire. We pay more per month for our portion of "covered" medical services than we do for our mortgage. I hate insurance companies.

Anonymous said...

I read this yesterday and am still horrified. This is not how things should be.

Anonymous said...

Appalling. Despicable. Criminal. And those are its good points. What I don’t get is the insurance company’s “thinking” on this. Let’s assume, for the sake of argument (er-hem), that they are interested only in money. What is more cost effective—paying for a few dozen pills a month to keep the patient healthy and seizure free, or spending orders of magnitude more money to pay for a visit to the ER and possibly a hospitalization? I’m not even considering the human suffering that would result if she had a seizure under the conditions Annie suggests. This has made me truly angry. Does Ms. Recite even listen to what she is saying? Unfortunately, her ethical co-workers have already quit.
--Queen Anne’s Lace

Anonymous said...

Spykenwayv=Vimpat? My insurance company does this to me and my neurologist's office EVERY.SINGLE.YEAR. During one phone call this year, a rep told me to ask my Dr. to switch me to Lacosamide because Vimpat was too expensive. No joke. Eventually the insurance co gave up and covered my prescription.

Anonymous said...

So then, as a Pharmacy Technician, I get to tell the patient the bad news. The patient tears me a new a-hole, calls me very unkind names and asks to speak to my supervisor. I try to explain what dipshits her insurance company employs, but somehow it's still all my fault. Honestly...I want you to get your medication. I know you need it. It is YOUR stupid insurance company that is being buttheads and I can't change that.

Anonymous said...

Dear Pharmacy Technician, This is nothing personal. I don't know you from Adam, but in this game that is being played, no one knows that you are a pharmacy technician unless you state it quite plainly, before you get too far in talking with patients. It is very, very helpful to be on the front line in telling the patient what is going on, but pharmacy technicians do NOT make decisions.

So many patients are stopped by the technician at the front counter and cannot figure out the next step, who to call, where to call, etc. and it is so very helpful when they can help explain what they know, because the patient has simply NO idea of who is telling them 'no' in this cloaks and daggers ruse.
Another health professional

fallconsmate said...

i have chronic insomnia. my doctor writes me lunesta 30 per month(which i can get as a cheap generic huzzah!!!) and my insurance will only cover 21 tablets.

so i have to then take up the pharmacist's time calling them instead of doing the phone call to order it that way, because the computer will not recognise that i'm filling it BEFORE the 30 days are up. every single time i'm out.

my mother has the same sort of issues with the idiots argung with her EVERY REFILL that she should take the generic for one of her scrips...when she's taking for narcolepsy, and the generic makes her sleepy. her doctor finally had to go toe-to-toe with the supervisor on that one, doing the "i have this many degrees, how many do you have?" talk.

RehabRN said...

Oh, the drug rationers at it again! Joy!

Of course, you don't need those maintenance medications, silly.

Some of our folks at the Hotel are on antispasmodics. Can't tell you how many times unknowing providers have said, "I don't think you have any spasms", discontinued the meds, then go bonkers when the patients go psycho on them (abrupt withdrawal is not a good thing for some of those meds).

I have learned to bite my tongue to keep from saying, "See I told you so." I just make sure I have the state ombudsman's phone number, so the patient can call and file a complaint against them.

Scary, but all too true. I second the psych med issue too. Been there and done that. Nothing like a little psychosis to get people working on getting the right meds.

Hattie said...

That bad. Dreadful.

jen said...

There is a bumper sticker put out by NorthernSun.Com that reads, "We already have death panels. They're called 'insurance companies'."

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