Premera refused to pay for my child's medication

[tavalon]

He's been taking it for 7 years and now they won't pay for it. They want to have their panel review it for medical necessity. In the meantime, I crush up my pills (same medicine) because he can't take pills and he really, really needs the medication.

I would be happier to have the Government between me and my Doctor instead of Premera. At least they wouldn't have their profit margin first on their minds.

I'm guessing they are soon going to refuse his epilepsy medicine. It's quite expensive and since he's autistic, he's unlikely to be very productive in society, so if he dies because they won't subsidize his medicine, what's the big deal, right? RIGHT!?!

In the end, I am not afraid of bogus government death panels. I'm scared of the Premera death panels and the United Healthcare death panels and the Cigna death panels and the Aetna death panels that are already in place. I apologize if I missed any of the other for profit health insurance death panels THAT ARE ALREADY IN PLACE AND PRACTICING MURDER WITH IMPUNITY!!!!!!!

[Hekate]

1. KnR, tavalon. Please write this to your congresscritters and to Obama's office.

I know that every lie the deluded wingnuts and their puppeteers spew about health insurance reform/health care reform is something that the insurance companies actually do themselves. And the insurance corporations do it for money. I've been saying for years that the US has a Third World health-access system -- and the statistics are finally showing that to be true. We're nearly dead last among industrialized nations in everything from infant mortality to adult life-expectancy.

Best of luck to you and your boy. :hug:

Hekate

[tavalon]

2. I'm going to a townhall tomorrow and hopefully will get the chance to say something

I have already written to Obama. Actually, I wrote the letter to Premera and placed the CC to President Obama. And yes, it got sent to both places.

[Mythsaje]

3. Okay...let me get this straight.

They're reviewing the need to cover epilepsy meds for a child who's epileptic? Seriously? That's fucked. Good luck at the town meeting. Try not to clobber too many freeper idiots, though I wouldn't fault you if you did. Hope you get the help you need.

On edit: K&R... This belongs on the Greatest Page far more than my bellyaching.

[tavalon]

5. The current medicine they are refusing is liquid lexapro

He has anxiety (many autistics do) and without it, he becomes panicky and obsessive compulsive. They haven't said anything about the medicine for epilepsy yet, but since he was taking the liquid lexapro for the last seven years and Premera and Aetna before that was paying for it, I wonder if the Trileptal isn't next on the list for "medical review".

[Mythsaje]

10. Sounds like hell...

Hope everything works out all right one way or another.

[tavalon]

12. Oh, it will. Poor Premera just doesn't understand that you don't mess with this momma bear

I just sent the aforementioned letter so we'll see what happens then. Since I'm able to cover this one, I haven't been as enraged as I would be if it was his Trileptal. But it was just as I was sending that letter that I realized that while our story doesn't include death, it is relevant to something the insurance companies desperately want to cover up. It is they, not the government who are standing between us and our doctors.

[Mythsaje]

18. It's a good illustration of the big disconnect...

I'm far more concerned about people with a profit motive standing between us and our doctors than a government that doesn't have such a motive (and better not ever develop one).

[northzax]

42. Yes, what's the famous line?

I'd rather deal with a government buearocrat who doesn't care if I die than a corporate one who's livelihood depends on it.

[madrchsod]

36. my wife works with autistic adults...

and they have no problems with their meds because the state pays for them. so if you want your child to have medicine put him in a state institution!

you are just another example of an unknown number of families that face this everyday. i hope that your son will be able to continue on his medications.

[jmm]

43. I use to work with children and young adults,

many of whom were autistic, and the ones the state paid for had the best care.

A friend of mine who has epilepsy had gone a few years without a seizure when she was on Mass Health but once she got private insurance they started giving her the run around when it came to her meds and she's been having an increasing number of seizures. After one of them when she was in a hospital and said she couldn't afford valporic acid she was offered folic acid because her insurance would pay for that :banghead:.

[tavalon]

46. Yeah, we make too much money to get any help from the state

When he is 19, he will get SSDI and 2 years later will be eligible for Medicare. In the meantime, come hell or high water, he's our son and we will provide what he needs. I'm fairly sure you're joking about the institution, but on the slim possibility that you aren't, the answer is a resounding no.

[Odin2005]

41. That's me without my Paxil and Concerta.

When I have an "Aspie Meltdown" trying to multitask at work that usually means I forgot to take my Concerta in the morning!

[PA Democrat]

56. Isn't lexapro an SSRI? Isn't it dangerous to quit SSRIs cold turkey?

Jeez, I know that it sometimes takes YEARS to find the right medications that help with autism. I'm sorry for the additional stress the insurance company is causing you and your family.

[unapatriciated]

48. It's been going on for years.

the second year into my son's illness (late 1991) is when I experienced my first review. Blue Cross not only suspended payment for my son's meds they would no longer cover the cost of his monthly visits to Children's Rheumatology. If that wasn't bad enough they stared to take back monies previously paid, leaving me in debt and scrambling to find money to cover his meds. They use this to force you on to medicare and insure that only the healthy are on their roles.
No profit in sick children.

[Mythsaje]

54. I hate the health insurance industry with a kind of fiery passion

because of things like this. I'd love to see it abolished in this country, but if not abolished, taken down a couple dozen pegs so all they can do is offer supplementary insurance to the already well-insured.

[unapatriciated]

55. I'm with you, I started a one woman lobby of both the house, senate and President.

for single payer in 1991. I sent letters made phone calls (telling my son's story and what turned into a 15 year fight with my insurance company) starting with bush1 and am still fighting for single payer. When my son turned 23 and no longer qualified for my policy they finally pushed him onto the medical roles.

Hopefully we will at least get a public option. That would be a starting point to purging the profit driven corporations who are killing and crippling with their death panel "reviews" from our health care.

[uppityperson]

4. That is very wrong. They need to cover it WHILE they review it

I am so tired of insurance companies trying to control health care. F them and their "profit margins" anyway.

[tavalon]

8. Seems reasonable doesn't it?

But I've been cutting back on my own Lexapro so that we have enough to crush up for him. This has been hung up for a month or more now.

[uppityperson]

13. Ask your doc or clinic if they have samples, explain wtf is going on

I know we used to get samples of all sorts of stuff when I worked in clinics. Not sure how much of that they are doing now, but it couldn't hurt. Perhaps your doc could write a letter also? How much is lexapro? Trying to think of ideas here.

[tavalon]

14. He's already called the number he was given and he was told

that if they change it to generic celexa, the board would probably find in our favor. He called yesterday to ask me if that might be something we would be willing to try. It has a higher side effect profile but I would be willing to give it a try. It's just that it isn't right for the insurance companies to be practicing medicine, especially when their motive is profit, not health.

[uppityperson]

17. Good he called and no, it really isn't right at all. I always counsel my

massage clients about insurance companies, that they are NOT out to help them but to make money. Often this comes as a surprise to actually hear this and an "oh, that's why..." sort of thing. I really dislike for profit insurance companies as gathering money and refusing to pay it out is really what they are about.

Best of luck and good wishes to you all.

On the other hand, it has cleared up here in PT and maybe we can see some Persieds tonight. Not sure if you guys have too much night light out there or not.

Best of luck again.

[tavalon]

35. My confusion is not with you but with the other poster

I used to be on Celexa way back when. It worked fine for me. My doctor moved me to Lexapro when it was the new thing - supposedly had fewer side effects because it only had the left handed isomer. If it were me they were pushing to get back on Celexa, I wouldn't care. I saw no personal difference in the way it worked or its side effect profile for me. But this is my autistic child with a really wacky neurological system and an inability to tell us if he feels bad from it or if it isn't helping as much (though we would likely know by watching him). I'm just not happy about this sudden refusal to give him the medication that has worked fine for the last seven years. And they just cut him off - wanna guess what cold turkey from Lexapro feels like? It isn't fun and I won't allow that, so I'm crushing my 20 mg tabs and measuring about 7mg for him (inexact but better than nothing). If we have to go to the generic to get him back on some sort of ssri, we will, but the point is that it isn't right what Premera is doing and I'm adding this as a data point, a little human boy data point.

[unapatriciated]

58. tavalon what state do you live in?

some states (like Ca) have strict laws regarding reviews and denial of claims. They put a thirty day limit on resolving the dispute. I have been through numerous "reviews" (they started in 1991 with my son )and learned that you need to put everything in writing when disputing them. When it comes to generic vs a name brand get your doctor to write a letter detailing why name brand is medically necessary and best course of treatment for your son. I went through this when my son was taking Neoral Sandimmun Cyclosporin. After two years of him being on it my insurance company wanted to switch him to the generic brand. My doctor wrote a detailed letter why this formula was the best course of treatment for my son's condition. It took a few months of letter writing and threats of lawsuits but they finally covered the brand name (which had better absorption and less side effects).
Contact your Insurance Commissioner, find out about the laws in your state and your rights. Quote them often when corresponding with your Insurance Company.

[jmondine]

6. I know how you feel...

... more than most folks here would know.

[tavalon]

9. That's kind of coy, hon.

For anyone following this thread, jmondine is my husband and my son is also his beloved son.

[Rhiannon12866]

7. This really is a crime.

There is no excuse for this, another example of insurance companies practicing medicine without a license. My doctor moved to MA from NY because the insurance companies were telling him whether his patients could be hospitalized. I sure hope this changes, especially for you and your son. Me, I haven't had health insurance since 2006. My current doctor gives a discount for cash. :hug:

[excess_3]

11. what would Canada do? (or anywhere else?) n/t

[tavalon]

15. Cover the medication, of course, as long as his doctor said he needed it

[excess_3]

16. you know this how?

how much does Canada pay?
is there a generic available?

[tavalon]

19. I've researched their system extensively

We are considering emigrating.

[excess_3]

20. is the US price 50 times the international price

is the US price 50 times the international price,
for the med in question?

[uppityperson]

21. what does "the international price" mean? Confused about that term. Thanks

What does that term mean?

[excess_3]

22. my understanding is, sometimes, drug companies charge

my understanding is, sometimes, drug companies charge
lots more for the same thing in the US than outside the US.
..................................
is the med in question, available
as a generic?

[uppityperson]

24. post #14 talks about generic. It wouldn't surprise me that there are different

costs for different companies, but not sure if it is drug companies or what all (insurance co's for instance). I would like to know though.

[excess_3]

25. hereis a link to some Wiki info

http://en.wikipedia.org/wiki/Citalopram

[tavalon]

26. I'm a nurse and have access to far more than wikipedia

I'm really trying to get what your point is here but I'm not getting it.

[uppityperson]

27. I'm a nurse and have access to far more than wikipedia also

Not sure why you are posting this, or what you are getting at either.

[tavalon]

31. I'm trying to figure out what excess_3 is trying to get at

I'm not understanding his line of questioning.

My kiddo has been on liquid lexapro for 7 years and now a panel wants to get between him and his doctor. Yeah, maybe we'll change the medicine but that should be based on the clinical picture, not Premera's bottom line.

[tavalon]

23. That's a really odd question but I checked a pharmacy in Canada

and I just called Walgreens. It's $231 in Canada and $191 at Walgreens. I have no idea why you asked that question but there's your answer.

[excess_3]

28. this stuff is off (expired) patent, in the US

how much does the generic stuff cost?

[uppityperson]

29. try here...

http://www.democraticunderground.com/discuss/duboard.php?az=show_mesg&forum=389&topic_id=6282409&mesg_id=6282462

[excess_3]

30. Buy Citalopram (Generic Brand) 40 mg - 90 Tabs $129.95

http://buycitalopram.com/

[tavalon]

32. ?

[uppityperson]

33. perhaps you missed this post on the generic

http://www.democraticunderground.com/discuss/duboard.php?az=show_mesg&forum=389&topic_id=6282409&mesg_id=6282462

[excess_3]

34. how is the side effect profile, different?

please enlighten me.

[uppityperson]

47. Maybe going back up there and asking the poster involved might be a better idea

than asking me. Thank you for continuing to kick this, but not sure what you are getting at by doing so.

[nadinbrzezinski]

52. Cover the care, but I am sure you knew that

jeesus age. this is a problem with a health for profit model...

Not in places like Canada or the UK...

[zbdent]

37. If you were a Repug, you'd have your own TV spots ...

but, since you're not, you won't get any traction from the media complaining about already having faced one of Sarah Palin's "Death Panels" ... the Govt. doesn't have them, the insurance industry already has them ...

[City Lights]

38. Sorry you and your son are going through this, tavalon.

:hug:

I do hope you're keeping your members of Congress informed about your health insurance situation. I write mine every time I encounter a new outrage. They need to hear from every one of us.

[TexasObserver]

39. Recommend

[Odin2005]

40. This is why this autistic person is thankful for living in Minnesota.

Here in Minnesota the disabled get our healthcare paid for by that state. Otherwise I would not be able to afford the medications I need in order to function mentally.

[tavalon]

44. Luckily, when my child reaches 21, he will be able to get Medicare

Until then, he is under my insurance and we have to fight with them.

[unapatriciated]

45. I faced Blue Cross "Death Panels" in 1990.

now my son is on medicare, which is where the Insurance Companies want the chronically ill. They so cut into their profits.

tavalon, I went through many "reviews" stay strong, The worst part of reviews is they can take back monies already paid and leave you in debt and struggling to find the money to cover expenses previously paid by your insurance.

[Odin2005]

49. KICK for Tav's kid!

:)

[earth mom]

50. I've come to believe that the medical industry wants anyone with Autism dead.

They don't give a damn and they prove it by refusing to pay for any treatments for Autism.

Medical insurance companies have been throwing mentally ill people away for decades and they are throwing these kids away now. :grr:

[nadinbrzezinski]

51. Hugs I wish I could do more than just hugging you

this is why we need single payer NOW... and why this shit has to stop!

[EFerrari]

53. They're a bunch of criminals.

I'm so sorry, tavalon. :hug:

[Canuckistanian]

57. You'd think that insurance companies would ease up

Now that so many people are screaming about price-gouging, denial of medical services and underpayments, they should be acting more equitably. They know their industry is threatened and the big profit days are over.

But I haven't seen any sign of them easing up.

Stories like this are only going to harden resolve to GET RID of these bloodsuckers.