formulary issue

Discussion in 'General Parenting' started by ysne58, Dec 6, 2007.

  1. ysne58

    ysne58 New Member

    Our insurance company has decided to switch pharmacy benefit managers as of January 1st, 2008. Yesterday I opened a letter from this new company that was addressed to my 14 year old son.

    I'm not sure how to handle the issue that they are addressing a 14 year old dependent instead of the policy holder, my husband.

    However after reading through this 2 page letter, I finally figured out that this jerks (insert your own expletives if you wish) have decided to remove a whole lot of drugs from the formulary that exists now under the present pharmacy benefits manager.

    One of the drugs they intend to remove is strattera, which is in the antidepressent class. The only drugs they are offering in its place are all in the stimulant class.

    At the moment I'm working through the sheer rage that these jerks keep thinking they can continue to play God like this. Stratter works for my son. None of the drugs in the stimulant class work as well for him and he doesn't do well with the side effects.

    I know other parents have this same experience. Maybe not with strattera, but with other drugs and other insurance coverage issues.

    These people have no business taking options away from us like this. The insurance industry needs to be taught some huge lessons. And I'm still struggling with the most effective way to do this.

    Cathy Anderson
  2. slsh

    slsh member since 1999

    First off, they probably sent the letter to your son because he's over the age of consent for psychiatric treatment in MN. Welcome to the nightmare that is HIPAA. Our lovely insurance company will not even speak to me about claims for psychiatric treatment for my 16 y/o without a *major* hassle that usually entails me faxing them yet another copy of IL's stature re: minors, confidentiality, psychiatric treatment, and who can talk to who about what. HIPAA defers to state statutes regarding privacy. One of these days, I may just make them talk to him directly about a claim - and I'll listen in for giggles. That should cure them. :devil:

    Secondly, I absolutely agree that it's absurd and in my humble opinion dangreous for clerks and bean counters to decide what medications are appropriate. We are stuck with- one of those mandatory mail-in plans, which is ridiculous for a kid who's medications change as often as the weather. Force me to buy 3 months worth of medication A, that will be changed to B in 2 weeks, buy another 3 months worth of B that will be changed to C in 2 more weeks. There's cost effectiveness for you.

    If the insurance is through a self-insured employer that has hired this insurance co to manage the benefits, call the benefits people at the employer. If not, call the insurance company and ask them for a waiver. Go up the chain of command if you get a hard time from the clerks. Explain why stimulants are unacceptable - would help to have a note or script from doctor.

    I go through this every year with- our insurance company, and it usually drains a couple of hours to get it all straightened out, but in the end thank you gets the medications that he needs in monthly quantities from the pharmacy that his facility uses rather than through the mail order place.
  3. nvts

    nvts Active Member

    Hi! Cathy, what I would recommend that you do is have psychiatrist write a letter stating that other medications (stims specifically) have been trialed and that this is the only medication that your son can handle.

    Make sure the letter is given to you and you send it to them certified. Give them about a week after you've sent it, call them and all should be well.

    Some companies even let the psychiatrist call and discuss it with the formulary to get verbal authorization. You most likely will have to sign a hippa form at the dr's in order for him to talk with the ins. company.

    Good luck!

  4. busywend

    busywend Well-Known Member

    I hope you can get somewhere with the insurance company. Like we need more things to juggle!
  5. ysne58

    ysne58 New Member

    Yeah I am going to be following the process with an individual exemption.

    I think the real reason they addressed this to my son instead of my husband is because they were hoping I would think it was junk mail and throw it away without reading it.

    There were several medications on the list and only one of them is prescribed for my son. If only the medication he is taking had been listed I might believe this was a mistake.

    The fact is, I'm tired of having to do this with myself or a family member ever other month or so. This company keeps doing something it shouldn't be with notice issues, and while i'm trying to get the bozo's at the state employee relations department to do something about that they move on to something else.

    Last July my doctor appealed the denial of a medicine I need to keep taking. They called my doctor's office and said they were denying the appeal and were not going to issue any kind of written decision. I called them and told them they were going to issue a written decision and at the same time emailed the bozos at the state employee relations department.

    November 20 comes along and I still don't have this document so I contact the company and the employee relations department. A week later I get a call from this insurance company, they did deny this appeal in July and did file it and chose not to sene me anything in writing. They also said that they were sending out a new denial that I could appeal. I contacted the the company and employee relations people and demanded the name and contact information of the agency that regulates this company.

    The next day the insurance company emailed me the name of the agency and a telephone number that was three years or more out of date. The employee relations department didn't bother replying for another week and instead of providing the information I had demanded, they sent me an appeal form.

    I still don't have a copy of the documents that denied the appeal my doctor filed for me in July. The state legislature and two unions are also inquiring into this cute little attempt to deny due process. I have taken steps to make sure this stunt will never be used again.

    But in the meantime I finally have an appeal form from the idiots at the employee relations department. (The fact that there are unresolved issues going back to 2005 that they never bothered to send me appeal forms for probably means this issues are still open.) I have demanded this information repeatedly and still don't have it. I've got an appointment with an attorney on Monday. If this goes to court just because I have to ask a judge to tell the insurance company to give me a document so I can file an appeal... well this is way beyond rediculous.

    And now I have yet another go round to do on medications on top of this? I think I may just have an opportunity to use this cute little due process stunt to make them change how they make these formulary decisions. If I succeed I will be making life easier for me, and for others too. I'm really sick of this though.

  6. Marguerite

    Marguerite Active Member

    Cathy, you send them a certified letter, saying, "I was told by [...] on [date] that my appeal had been denied but this would not be given to me in writing. I am now writing to you in order to have some form of acknowledgement of status of my appeal logged somewhere, in writing. if this is incorrect, you will need to notify me in writing by [a week's time]. Failure to so notify me will be considered acknowledgement that the contents of this letter are correct."
    (or words to that effect).

    Failure to give you written confirmation is an old trick used by bureaucrats everywhere as way of opting out of possible future recriminations for refusing to allow whatever-it-is you asked for. This way, if at some later stage there is outrage over what they have done, they can go through their files and honestly say, "We have nothing in our records confirming this." But if YOU have a copy of your letter, minuting events, then a record exists, somewhere (and it is a record which confirms and explains the lack of paperwork on their part). And your letter must clearly have existed before the investigation (if such investigation ever happens) - it can't be something you mocked up later on and backdated. Hence sending it registered mail. Getting a JP to witness and date your copy for you at time of sending is also a good safeguard.

  7. ysne58

    ysne58 New Member

    I've got the facts of this verbal denial well documented already and I have sent several written demands to them via their web site and responded to by email. There is absolutely no question that they handled this, in this way.

    This issue is before the state legislature because I contacted my representative shortly after they told me that they did in fact do this. I have also brought this little stunt to the attention of two of the unions who represent state employees, a newspapter reporter, and insurance cooderinator at the university of minnesota and anyone else I can think of who might have to deal with something like this. I do believe I have cut off their ability to pull this little stunt on anyone else. Its as illegal as can be and its also outrageous conduct.

    I'm also going to talk to this attorney about alternative for the formulary issue. I'm still too mad about it to deal effectively with these people right now anyways, so another perspective will be helpful.
  8. ysne58

    ysne58 New Member

    I did see my attorney today. He doesn't have time to handle the due process issue for me. I asked him for a referral. He said he would see what he could come up with. It was not very comforting when he told me that even with my disabilities, I can handle this issue better on a pro se basis than 95 % of the attorneys out there practicing.

    I didn't even ask about the formulary issue. Looks like I will be better off pursuing a systemic change of this on my own.

    I guess we don't get to pick our battles. Looks like they choose us.

  9. ysne58

    ysne58 New Member

    I finally went on the insurance company website about the formulary issue, they told me to contact the pharmacy benefits company. I'm saving that and then giong to contact the ocmpany, probably next week after I see my own doctor about all the other medications on the list.

    I do not think removing straterra from that formulary is appropriate when the only alternatives being offered are in a completely different class of medications.

    I've got the legislature and the DOLI looking at the due process stunt. The specific medication involved is phentermene. My doctor prescribed it for weightloss. It has helped slow down and then prevent further weithg gain. NOt because its a weight loss medicine. The reason ist working is because when you add phentermine on top of an antidepressant (and it doesn't seem to matter which one) for some people, you have an effective treatment for Obsessive Compulsive Disorder (OCD). Part of my eating problem is tied up with Obsessive Compulsive Disorder (OCD) issues. But I also have a problem with compulsive scratching to the point where I developed severed chronic dermatitis. That cleared up after I reached an effective does of the phentermine. The insurance company stopped covering and I was off the m eds for two weeks looking for a way to get the medication that I could afford. During that two weeks the dermatitis came back full force.

    That's when I did the research on phentermine and Obsessive Compulsive Disorder (OCD). Those studies were published in 1993 and 1994. There are at least two patents out on it covereing phentermine + some of the antidepressants.

    We found a solution I could afford, I've been paying out of pocket and the dermatitis is gone again. I think I can guarantee this stunt won't be pulled on anyone else, cause I've contacted the legislature about the due process stunt. I'm still working on my own coverage.

    I think I'll try filing a complaint against the head of the medical part of the insurance company with the medical practices board for violating the Hippocratic Oath-- the part where the physician promises to do no harm.

    A law suit isn't cost effective. Creating nasty headaches for these people just might work though.
  10. ysne58

    ysne58 New Member

    I did contact the insurance company about the formulary issues. They provided me the web address to contact the pharmacy benefit management company. The company has nothing that would allow a disabled person like me to contact them over the web with these issues.

    I did figure out who the president of the company is. I took a guess at his email address and sent an email regarding this ADA violation. I explained that I had formulary issues that I need addressed and that I expected this ADA violation to be taken care of immediately.

    As for the phentermine due process violation. I finally (with the help of the legislature) extracted an explanation of what they think they are doing and why they think they are in compliance with MN. Stat. 62M. They sent me a copy of their letter by email. Their policy and procedure does appear to comply with the statute. However, this creative attempt to take a written appeal and call it a reconsideration in an effort to sidestip this legal procedure is very definitely illegal.

    On top of that, they didn't even have their facts straight on when and how I have contacted them and when I got the prescription filled during the 6 weeks that I actually had authorization. I'm not sure yet whether I actually have them over a barrel. I need to see what the people I copied my response to this letter do with this before I try anything else.