how do you fight this health insurance

[marty031649]

What is the name of your state? ok

my husband has a precancerous condition, called barrets syndrome. the treatment prescribed by the gasterologist is, aciphex. the mail in drug company and says the prescription has been cancelled by the insurance company. how can they take charge of someone's life, what can i do. i was thinking of calling the health insurance carrier and asking for a written statement as to why they are canceling. i have a letter from the doctor with the diagnosis and treatment he specifies.
help!! i don;t want my husband to lose control of this so that it get worse!!

 

[Beth3]

Saying the prescription was "cancelled" by the insurance company just doesn't make any sense. Insurers don't cancel prescriptions. They may decline to pay for a medication if it's not a covered expense for some reason but they don't just CANCEL the Rx.

By all means, call the insurer and ask for an explanation.

 

[concerned1]

I have seen Barrets Syndrome treated with an acid reflux medication. Is that what you husband it taking? If so, with the introduction of Prilosec OTC, Proton Pump Inhibitors (PPIs) are not covered anymore by a lot of insurance companies. In my experience, you can always appeal the decision and ask for the particular drug you are taking to be covered.

 

[lkc15507]

Do call the insurer to ask for an explanation. It may be that there is a simple need for an "override" based on the medical necessity of the drug. Many pharmacy benefit managers exclude drugs that may be excluded for numerous reasons. Often the PBM will require that the medication have approval from the plan prior to dispensing.

lkc15507

 

[tammy8]

Sorry Marty for your husband's health.

Nothing compared to what you guys are going through but these health insurance companies really got us. I have to take otc allergy meds for allergies I have had for yrs and nothing really helps. Talk to your dr and see if he can talk to the insurance company or atleast help you with samples! Good luck and better health to you and your family!

 

[frustrated80]

first, i just wanna say i'm really sorry to hear that.

since i do not know the details of your insurance policy, i can think of a couple scenarios.

1. prescription insurance companies have this list of drugs that they cover called their "formulary". if they took aciphex off of their formulary, the prescription insurance company just won't pay for that medication, period. and when they said that the prescription is "cancelled", that doesn't make any sense at all. once the MD calls in the prescription your mail order pharmacy, it doesn't just disappear. (it should still be on their records and still be fillable) it sounds like your husband really should be taking the medicine. the only option you would have here would be to pay cash for it.

2. the insurance company won't pay for the prescription unless they get a "prior authorization" from the physician explaining why he needs this prescription and why he can't take something else (say, something that has a generic equivalent available.....aciphex doesn't have a generic available yet....and it is fairly expensive)

i'm an intern at a pharmacy and when things like this happens, it's really a shame......i am hoping that #2 listed above would be what's really going on....because that way, at least you have a chance that they will pay for it.

hope everything works out.

 

[marty031649]

Thanks to you all for you help and kind thoughts.

i have talked to the insurance company several times! and finally one of their customer service people told me that if the doctor would call, that would authorize them to fill the RX.

Lets hope this works and that we don't have to pay for the aciphex.

Thanks again for all your kind thoughts and help!