Tackling the insurance company, one lupus issue at a time!

This past Saturday morning was supposed to look like this:

Johnny stayed home with the girls.
I went to Starbucks to blog.

But I made a fatal mistake on the way to Starbucks. I made a stop.

Trying to be efficient, I stopped to drop off some new prescriptions at my pharmacy just down the road from Starbucks. I thought it would be an easy in and out, as I wasn't going to wait for them to be filled. Because I use my trusty pillfolds, I knew I had more than a week's worth of all three prescriptions left, so I had plenty of time to pick up the filled prescriptions later in the week. I just wanted to drop and go.

But drop and go, I did not. In fact, I never made it to my sweet caramel decaf skinny latte, and my week's worth of blog posts were never written. Because while at the pharmacy, I had a run-in...with my insurance company!

Drat those insurance companies! If only the hours I've spent talking, debating, disputing, defending, and arguing with my insurance company were billable! Many of you have been there. Perhaps some of you are on hold right now, waiting to discuss yet another medical claim that you've either already paid, shouldn't be paying, or have no idea what it is. Believe me, I feel your pain.

But this insurance inquiry shouldn't have been painful. With the reset of the new year, my insurance medication cap of $1500 resets to zero. Thus, I figured I should take advantage of exhausting that cap on a three-month supply of Cellcept. (If you remember, I'd exceeded my medication cap about three months into last year, because of the high cost of the drug. I shopped around, and ended up switching  to Costco's pharmacy, where I pay a very low cash price and bypass my insurance all together. With the move to Costco, I save over $600 a month!)

But with the new year, I have $1500 to burn under my insurance, and I thought I should take advantage of it. (As an aside, I have new insurance starting Feb. 1st, which does not impose a medication cap, so I had even more reason to use my insurance for this final month.) So when I dropped off my prescriptions, I mentioned to the pharmacist that I would be using insurance this time. She said no problem, took my insurance card, entered my information, and out spit a rejection. It appeared that my insurance coverage had been terminated. What???!!!!!

Of course, I knew it hadn't been. I have documentation at home indicating that both my current insurance and my new insurance starting on Feb 1st are in good standing. But that's not what the Costco computers said.

The pharmacist was extremely accommodating, and tried several different things, including a phone call to the insurance company. With an insurance company's representative on the phone, she was able to get the computers to accept the insurance. But then there was still a question of cost. With insurance, Costco was saying I owed $120 for the three months of Cellcept, I thought I should be paying close to nothing, and my insurance company was saying over the phone that I should be paying $1085. Double what????!!!!

Thankfully, everyone on both ends of the conversation was very patient and understanding. And everyone was solution-oriented. In an effort to make it most cost-effective for me, we batted around the idea of waiting for the new insurance to kick in (this coming Sunday), or just filling one month's worth of Cellcept under the current insurance, rather than three. We also considered issuing a claim, but in the end, we were able to resolve the issue.  I WAS able to use my insurance, and I didn't have to pay thousands of dollars. I did pay more than expected, but that's okay. I now have a .01% better understanding of how my insurance works. Why does it seem to get more confusing each time I have an issue?

After more than an hour at the pharmacy counter, I was spent. I bagged Starbucks, wrote this blog post in the parking lot of the pharmacy, and headed home, WITH prescriptions in hand. After all that time, my pharmacist had plenty of time to fill them. So much for a drop and go scenario!  

Although the entanglement was definitely not how I'd planned to spend my morning, the exercise was productive. I spent about $80 less on my Cellcept than I would have had I not asked the insurance question, and even more when you account for the other two medications I filled. Financially, it was worth the time and energy. And you know? It almost always is.

I wish I could say that it doesn't pay to fight. I wish we could just file away those Explanation of Benefits without perusing them, turn a blind eye to charges we don't fully understand, or just pay those medical bills without scrutiny. But financially, we'd be losing money.

There is a HUGE benefit to reviewing those charges. If we seek to understand the bills that come in, and double check to make sure that we're not being overcharged, we're actually asserting ourselves in the face of our disease. We're empowering ourselves, educating ourselves, and perhaps saving a little dough along the way.

A girlfriend of mine recently shared the following story, reiterating just how aware we should be when it comes to our medical bills. If we're not double checking the system, who will?

She recently received a medical bill in the mail for $230, checked that her insurance had paid it, and called to explain that the bill had previously been paid by the insurance company. They struck the bill from her account, but after that call, she received that same bill not once, not twice, but FOUR additional times, each telling her that she, as the patient, was responsible for the payment. She was finally able to get the matter resolved, but it was a difficult process. But with with $230 on the line, she knew it was worth it.

So keep on reviewing those bills, checking those charges, and making sure you're being billed appropriately. And for those of you with a call pending to your insurance company, may the force be with you!


Maggie said…
I'm sorry to hear about your insurance battle (been there!). Have you tried the generic form of CellCept? I took mycophenolate for 2 years and it was great. Eventually, it stopped working for me and I just started Benlysta. My understanding is that insurance companies are willing to cover non-generic CellCept for kidney transplant patients because the risk (possible kidney rejection) makes it worth the relative cost. However, for other uses, the generic seems to work very well for many people. I had no side effects from generic CellCept after my body got used to it and the cost for me post-insurance was about $30/month. Good luck!
Sara Gorman said…
Hope the Benlysta is working well for you! I am on the generic of cellcept...which definitely helps in the price. My recollection is that in 2004, when I started cellcept the first time, I didn't have a generic option. So i'm just thankful for the progress. The costs stink, but when these drugs are working, it doesn't seem as hard to swallow, you know? Hope the same can be said for the extra time and energy of your infusions! :) thanks for commenting!
Donnie White said…
Strong points, Sara, These reminders are worth noting. I'm sorry to hear about the things that you had to go through because of your insurance company. Fortunately, there are other health plans that you can opt from, so you don't have to be stuck in so much red tape. You can get ones that will cut the health costs down more efficiently, without having you go through hoops. Take care, and stay strong!

Donnie White @ Good Health Quotes
Sara Gorman said…
Thanks for commenting! Thankfully, my new insurance has kicked in, and I'm seeing a nice savings on my RX. Just in time, too - because with the rising cost of another lupus staple drug, plaquenil, I can only handle one costly drug at a time!
WebbRowan said…
Insurance is a really tricky situation and I'm actually surprised that there aren't more on the ball agents out there who are explaining how insurance works to their clients. It helps to get a proper understanding of how all these plans work!

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