I am a Registered Nurse of nearly 14 years and recently I became a Family Nurse Practitioner. I’ve also been a patient my entire life. Transitioning from patient to RN to health care provider has been an interesting challenge that I’ve enjoyed greatly. (Though being a patient these days is a little more complicated with all that I know about the inner workings of the health care system.) So as I’m learning to diagnose and prescribe I’m finding these incredible barriers put up by insurance companies. I will unwittingly pick the ‘wrong’ drug and my patient (with health insurance) will be subjected to the runaround of the ‘prior authorization’ process. Fortunately our office has a dedicated RN to deal with these issues; sometimes she spends days collecting documentation and talking to various insurance company staffers, while a patient suffers, just to ultimately be denied. The drugs that are denied run the gamut from HIV medications (for which there is no reasonable substitution) to $4 formulary drugs (which really don’t even seem worth her time to fight but if she doesn’t the patient goes without).
Below is a letter I personally wrote on my own behalf as a patient as an appeal to my health insuranc e company. I believe the issue it addresses can be broadly applied to the above situation and feel that this issue simply must be addressed.
Humana Insurance Company
Grievance and Appeals Department
PO Box 14546
Lexington, KY 40512-4546
Appeal of most recent decision of 2/17/12 regarding Nexium twice daily for feckalyn (Member ID: 666666666).
To whom it may concern:
I am writing you to protest a number of recent denials passed down by your pharmacy (3 to date but I expect more).
I am a new customer to Humana. While trying to get my prescriptions shifted over to you I have come up against the most frustrating brick wall I have encountered in years. I take 40 mg of Nexium twice daily. I have taken 40 mg of Nexium twice daily for nearly 10 years because in 2002 I was diagnosed with erosive esophagitis. After a multitude of drug failures (Prevacid, Prilosec, Protonix, Propulsid, Zantac, Tagamet, Dexilant, Prevacid 24 hour OTC, Pepcid, and a variety of OTC antacids in a multitude of combinations with these drugs) and lifestyle changes (I increased exercise, cut out coffee and carbonated beverages and spicy foods and other irritants, ruined two bed frames raising the head up 30 degrees, chewed non-mint gum religiously after meals, completely stopped drinking alcohol, and never lie down after eating anything for at least 2 hours) my provider and I finally found that 40mg of Nexium twice a day (along with the above lifestyle management techniques) essentially alleviated my erosive esophagitis and its symptoms. I have done everything the doctor ordered and then some (the chewing gum thing was a journal article I found on my own) to try and avoid writing this letter to you begging for your mercy but obviously none of it has worked because you keep blithely deny my health care providers’ requests.
In the last 10 years I have had a number of different health insurance carriers and plans and NEVER have I been outright denied 40mg of Nexium twice a day. I’ve had to have prior authorizations completed in the past but the drug was always approved after one request. The last two plans I had didn’t even require a prior auth for the twice daily dosing. Over the years I have become very aware of Astra Zeneca’s patient assistance programs because I have also had periods of being uninsured and this drug is astronomically expensive. Sadly the “Purple Program” is not available to people with any sort of insurance who can’t afford the medicine. They offer co-pay assistance for the insured but for those of us with substandard coverage they have no mercy. Nexium is one of Astra Zeneca’s ‘blockbuster drugs’, making them billions of dollars annually. I suspect that in 2014, when Nexium is (supposedly) slated to go generic, you will not waste your ‘medical decision maker’s’ time fighting claims like mine. You will be better served financially to take on those gastroenterologists who dare to try and prescribe Dexilant twice a day because that will actually save you money.
I am followed closely by a gastroenterologist for my condition. I have had 3 esophagogastroduodenoscopy’s (EGD) since the one that showed I had erosive esophagitis in 2002 and they all indicated that the 40mg of Nexium twice a day was helping by showing the erosive esophagitis had resolved. Unfortunately I continue to have daily refractory gastroesophageal reflux disease (GERD) symptoms if I don’t take 40mg of Nexium twice a day. When I have erosive esophagitis I can barely function. When I have severe refractory GERD symptoms I am not much better. It’s an anxiety-inducing cycle; which is vicious for me because increased anxiety leads to increased stomach acids. It’s painful but it’s also infuriating and disenheartening not to be able to control the pain through lifestyle modification and affordable medicines.
At this point you may be questioning my audacity in wording my letter in this manner. I am questioning your audacity in having a ‘medical decision maker’ rotely deny a medication based on nothing more than a company policy set to save you money. How dare you pretend you can outweigh my medical providers of the last 10 years and their experience with me as a patient and the thousands of other patients they have treated. How dare you blithely suggest that I try another medication, completely dismissing the gargantuan effort I’ve made for years to try and find another medication combination that works for me so I don’t have to write letters likes this? You deny me my medicine three times based on a prescription request and a single EGD (that seemed to be summarily ignored after I spent hours tracking it down and getting it to my GE doctor).
When I call to speak to someone at your company I am constantly accosted by how much Humana cares about me and my health. The soft toned woman assures me that I matter to you, that you want me well and that my premiums are being sent to a benevolent caring company. Yet keeping me from redeveloping erosive esophagitis, an extremely painful condition, that could potentially lead to me having barretts esophagus and cancer seems to be of no concern to you. Are you so short sighted that you can’t see that the prevention far outweighs the cost of the cure? Or do your actuarial tables tell you that I’m likely not going to have this policy long enough for you to end up treating any negative health sequelae I may experience due to this denial?
You’ve also suggested that my doctor can call and discuss his rationales with your ‘medical decision maker’. How do you expect my busy gastroenterologist to stop his day to have this ‘peer to peer’ conversation with your ‘medical decision maker’? He can’t even bill you for this time. This surely is just a tactic to keep me from getting this expensive prescription because you know that most providers are not able to make these sorts of calls on the daily basis that companies like yours are asking that they make them.
At this point, frankly, I have next to zero faith that anything I, my trusted health care providers, or even Jesus Christ himself say to you is going to change your mind. I am venting; I find myself wondering why I’m even bothering and why I’m remaining so civil. Do not think that I don’t understand that you would not remain in business if you gave every drug to every provider/patient that requested it. But please don’t continue to insult my intelligence with these asinine denials, pedantic automated phone calls, and supposed requests for further information/action on my part that could sway your ‘medical decision maker’s’ mind. Just tell me to go away and suffer in silence because that’s what you really mean.
Obviously this letter is written from an emotional and personal perspective; it's long and a bit messy and imperfect. My dual roles as a provider and a patient in need of care has brought the issues of our for-profit (and broken) health care system right into my living room. I fear that, with the new Affordable Care Act
requirements that insurance companies cut their overhead costs and actually spend 85% of our premiums in providing care for us, that we as patients and providers alike will be hearing stories like mine more and more often. Money has to be made somewhere otherwise the insurers (or the drug companies or us providers) would just give up entirely and then where would we be?