Thursday, December 11, 2008

HR the ultimate authority on my medical prescriptions

Apparently those folks in HR went to medical school and know exactly which prescriptions are best for me. I kid you not. That's pretty much what my insurance company told me. And if I want my prescription covered by some silly ol' insurance policy then I have to go to HR and ask them to please put it on the list. And if they feel like it, they can. Really. I'm not making this up.

Yesterday I finally had the long-awaited medical follow-up wherein I learned that I don't have cancer but I do have some pesky but common female-getting-older issues. TMI for my male friends so I'll stop there. Suffice it to say my Doctor prescribed some pills. Brand name. She warned me there is a Generic equivalent but that it wasn't the same and was missing, for my issues, a key ingredient, and thus she wanted me on the brand name.

Red flag - red flag - red flag - "Danger Will Robinson." Prescribe a brand name and try to get insurance to pay? Ha ha ha. So I called my insurance company to check before I did anything stupid like listen to my doctor and fill the prescription.

Turns out for a mere $45 copay for the "third tier drug" (aka "unfavored" b/c it's a brand with a generic equivalent) plus the difference between the generic and the brand = a mere $120 a month for my new drug.

But wait, can't the doctor write an exception notice or something to the insurance company and explain why the generic equivalent is a mere equivalent and not going to work for me? nooooooo.

If I want the brand name drug, I need to take myself down to HR, locate the person responsible for choosing our plan, and share with her/him the intimate details of my medical health and history and why I need this particular pill and why he/she should add it to "the list."

Does my medical company understand the difference between a generic equivalent and a generic equal? Apparently they don't care. There is no mechanism to override the approved drugs on HR's list choosen by those HR folks with an apparent medical degree.** My doctor does not know what's best for me medically. According to Insurance Company, only HR does.

So my response to the insurance company? "I don't think I'll fill this prescription. Instead, I'll go to the doctor Every Single Month, pay my co-pay of $25 and let you pick up the other $175+ while the doctor monitors my ailments and explains why the drug she prescribed would make me feel better and see you next month (and give me a free sample)." Somehow I think paying for my silly drug would be cheaper for them. And my snarky comment might've put me in the red on "kindness" points....

**This is not a diss on HR people. I understand that they have a job and guidelines and are likely quite knowledgeable about the statistics and choose drugs based on the good of the people in the company as a whole as balanced against costs. and the fact that my insurance company does not have an override mechanism is not my HR's fault. But the result from my silly insurance company's policy is that my HR person's choices trump my Doctor's recommendations. and THAT is the target of this rant. Believe me I love my HR people.


brightside-susan said...

I went through a similar situation when a doc wanted to do a head and neck CAT scan. Insurance company said head was enough, even though doc wrote bg explaination why the neck was needed. Battles ensued but doc gave up and he paid for the neck portion! By doing that it gave him the information he needed an I avoided futher testing.

He is a good man.

The insurance companies seem to be full of short sighted actuaries.

Lakeland Jo said...

I hate insurance companies. I was income protected when I was off sick last year ( ten months) and they only paid thirty three percent of what they should have. Now in court. I loathe them.

JO said...

Gotta weigh in here - HR AND a former insurance employee (carrier and broker side) - but am weighing in to help ya with the process.

Have your doctor write a simple explanation of why the drug is important. (ie: "I have prescribed XYZ Drug, in its brand name form for MEH to treat an ongoing medical condition. While I recognize that there is a generic equivalent, it is missing a key ingredient that is necessary for therapeutic purposes for this condition.". Then take that to the HR person in charge of the benefits and no explanation is needed other than "I have an ongoing medical condition", and the need for the brand pharmaceutical to be covered at the proper benefit rate.

As an aside - the drug may be considered a "designer drug" (ie: Lipitor, Advair, etc - which are expensive, heavily marketed to the average joe and over prescribed by physicians who enjoy the pharma rep's free lunches and trips to hawaii)which many insurance companies and employers decide to either not cover or to cover at a sucky benefit level.

These "designer drugs" are mostly targeted at "life style issues" like hypertension, being overweight, high cholesterol, and the like - and drug companies/employers would rather fix the systemic issue than throw a pill at it. BUT - there are safeguards built in to the system for situations just like this.

I have an ee here at the office who has a list of prescriptions that must be brand name - there is a binding ingredient in many of the generics of his scripts that he is allergic to. After working with the insurance company (through their pharmacy review department), and letters from the physician indicating a life threatening allergy to the binding ingredient, his scripts went from $1500 a month, to $80 as the insurance Co now covers these brand names at a generic level for him only. Of course, YMMV.

Cheri @ Blog This Mom! said...

Name NAMES. Take the biotches down on the World Wide Web.

Seriously? This totally blows. Like how PapSure tests aren't covered, but Viagra Rx is?

Stuff like that.


Shelly... said...

I just experienced that recently when I tried to fill a brand name prescription. So, I guess our insurance companies have medical degrees too? I was slightly p.o. to but it mildly! BTW, been a stalker for a while and thought I would finally comment. I found your blog through Whatever Katy (who happens to be my stepdaughter and one of my best friends).

Carol P. said...

Man that sucks! I know you have nothing better to do than tilt at the windmills of bureaucracy. And didn't dilbert do a series on descending into the bowels of hell to talk with benefits or payroll a while back? That's how I feel whenever I have to deal with these folks (Sorry JO!)