Discussion in 'General Parenting' started by Shari, Mar 9, 2010.

  1. Shari

    Shari IsItFridayYet?

    I have spent most of the afternoon going thru Wee's records to dig up when he took what medications and the reasons we discontinued them.
    Two weeks ago, we tried Intuniv. And for the first time in a long time, a medication actually seems to help him. (Risperdal was a miracle drug for about a still helps curb aggression, but not like that initial period of it). His doctor called in a prescription for it yesterday.
    I have just spent 2 hours on the phone. Now, we are all writing letters, stating why this drug is necessary. Why Vyvanse and Ritalin and Tenex (the drugs the insurance company wants him to take instead - since when are they the doctors!) aren't options. Then we'll wait a month, and maybe, MAYBE, they'll consider covering it at some level.
    I just want to scream. We're not talking about some kid who just "needs a little more focus in the classroom". We're talking about a kid who isn't even IN a classroom anymore.
    This system makes me so angry.
  2. gcvmom

    gcvmom Here we go again!

    Have you asked the doctor to write a letter of exception for this request? Sometimes the insurer will reconsider if the prescribing doctor indicates what's already been tried, failed, and why this is medically necessary. It's worth a shot.

    I can appreciate the disappointment. :(
  3. slsh

    slsh member since 1999

    Shari - you might try calling HR at work (yours or husband's, wherever the ins is thru) and speak to them. I had a bear of a time when our ins co would only pay for the 3-month supply of medications for thank you thru the mail-in rx company, not for monthly supplies through a local pharm. It was utterly ridiculous because he was unstable at the time and his medications were changing weekly. That's not cost savings, that's waste. Anyway, a call to HR and I got them to waive the 3-month supply requirement as well as the requirement to use the mail-in rx company.
  4. nvts

    nvts Active Member


    I would also suggest (aside from the other's suggestions) contacting the manufacturer - they're also usually willing to help out in these situations.

    Good luck!

  5. flutterby

    flutterby Fly away!

    I'm with you on the system. I think if they did a cost benefit analysis, they would find that it actually costs them more to have a department geared solely for medications and prior authorization for prescribed medications than it would to just cover as prescribed. For all of the medications I've had to have a prior auth on, only one was ever denied - and they used a BS excuse. (It was for lidocaine patches. They don't want to pay for them, but are more than happy to pay for narcotics to control pain.) It's ridiculous.

    Can your doctor give you enough samples to get you through?
  6. klmno

    klmno Active Member

  7. Shari

    Shari IsItFridayYet?

    We are appealing it. The doctor and the SpEd teacher are writing letters. I am copying notes of side effects from the other medications (and we're also not talking things like ...weight gain, nausea...those medications made Wee's behavior less tolerable (sometimes drastically so)) to send to them. The doctor is giving me samples. I think the OK doctor will probably send some, too. I have a friend who's a pharm rep and he's trying to get contact info for the mfg so I can apply for assistance thru them.

    Overkill, I hope. I hope ins will approve it.
  8. gcvmom

    gcvmom Here we go again!

    You should download that coupon anyway while it's fresh in your mind (I did 'cuz we're trialing that medication right now). It's good until the end of this year.
  9. Shari

    Shari IsItFridayYet?

    I did! Thanks!