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[WilliamPitt]

This message was self-deleted by its author (WilliamPitt) on Fri Apr 4, 2014, 02:41 PM. When the original post in a discussion thread is self-deleted, the entire discussion thread is automatically locked so new replies cannot be posted.

[truebrit71]

1. Hall-of-Fame Bullshit artist...

....you nailed it the first time 'round...

[WilliamPitt]

3. I long for a time machine.

I helped, in my own small way, to promote this thing, because of the pre-existing conditions aspect that would benefit my wife. I feel like a fucking dupe.

On edit: I AM a fucking dupe. Last time that happens.

[truebrit71]

11. My wife is a breast cancer survivor...

...and I was in the same boat regarding the pre-existing condition thing...not encouraging to hear that it too was a bait-and-switch...

[wordpix]

546. I'm a cancer patient---without ACA I would have NO insurance

So far my med. bills have been astronomical for specialists, diagnostics and major surgery, but most have been paid by insurance. Without ACA my pre-existing condition would make me ineligible for any insurance, and right now I'd be broke and would be looking at selling my condo---this after a lifetime of work and nearing retirement age.

So I thank Pres. Obama from the bottom of my heart. Just remember he tried to do more but was blocked and compromised by the repukes, who are still trying to end O-care. Direct your anger where it needs to go---against the repugs

[truebrit71]

550. I hope your recovery is 100% successful...

...but I will be angry at whomever deserves it...

[wordpix]

554. Wm Pitt---pls. inform your Congressional rep about this

I was having probs with my private insurance co. that said I'd be cut off from finishing my contract before the ACA became operational. I also had probs with the ACA website in my state, making calls on way-too-busy phone lines, etc, and I contacted my Congressman's office. They gave me a health care constituent services rep, who was invaluable in dealing with my complaints. I had her email address and phone no., and we were in regular contact as each problem cropped up until the resolution.

[Jefferson23]

565. Sounds like good advice, hopefully that may help Will's wife.

All the best to you with your recovery.

[Dorian Gray]

709. This is great advice

but it sucks that we have to do this and advocate so hard.

I truly wish the ACA went further. In the deepest recesses of my heart, I pray that this moves toward Single Payer someday.

[Mojorabbit]

23. My copay (medicare part d) for my MS med is 1650 a month

I have had some help from grants but that is running out so I will have to go off the med again. I don't know who can afford that kind of copay. You would have to be a multimillionaire to do a lifetime of this medicine. I hope you can find some help so that she can resume her treatment.

[TrollBuster9090]

204. For which medication? Just curious.

A) For which medication? (Is it an experimental drug? As I understand it, there is no effective treatment for MS, just standard drugs (like corticosteroids) that manage the symptoms and episodes; while some of the experimental ones like Amantidine haven't been proven effective, and therefore are not covered.)

B) I thought Medicare Part D was now obsolete, and

C) That's a copay of $20,000 per year. I thought the ACA limited copays to $5000 per year, unless Medicare isn't included, or you're talking pre-ACA?)

[Mojorabbit]

220. Aubagio. I was in the experimental trial for several years and then the FDA approved it

and I am paying for it at this time. It is Medicare with the part d plan from United. It is a pill which is glorious after doing the injections for so long. I still do the steroids etc to manage symptoms.

[steve2470]

222. I looked up Aubagio to help out Pitt

It's damn expensive at retail prices, $4,868.41 a month. Good thing you can get it !

[truedelphi]

358. But I think she is saying she could afford it for a while,

But now the $ 1,600 a month means she cannot.

[Pharaoh]

538. But how much does it actually "cost" to make the drug?

This is the question that is never asked by anyone. Why is that?

Most of the chemicals in drugs are super cheap. But they can charge what they like as some people need these drugs just to function, or to just stay alive. Yay capitalism and for making a profit on your life/death.......

[steve2470]

541. excellent point nt

[Hoyt]

579. While drugs are too high, it's not like you do a google search and make it in the kitchen.

There's a lot of research, failures, expensive FDA approval, big lawsuits when an adverse effect occurs, etc.

While I would have no problem with all drug research, production, etc., being done by the government, they would likely not pursue a lot of these type of drugs.

[Pharaoh]

654. Sorry but I don't buy all that shit

viagra was discovered by mistake, researching a blood pressure drug. Viagra = $18.00 per pill.

I don't know but do the math. The chemo drugs are astronomical.......why? Because people are told they will die with out them. Not necessarily true either BTW.


But, agree to disagree. Don't want a long argument thread!

[Hoyt]

658. Then, why don't a couple of unemployed PhDs down the street make them and sell at half the price.

[Pharaoh]

659. They would be arrested.

[Pharaoh]

660. but you can get a generic in Canada for about 3 bucks.

[Hoyt]

661. So, it is more difficult than you suggest. Like I said,

let the government do it and pray the white wing Republicans keep funding drug programs, like they back all other social programs.

[Doctor_J]

389. Medicare part d was the prelude to heritage care

Krugman called it the middleman multiplication act.

[Hoyt]

656. Definitely better before 2006- no drug coverage, elderly doing without, cutting pills in thirds, etc

[wordpix]

548. cannabinoids show promise for MS

http://the420times.com/2013/10/cannabidiol-could-help-treat-multiple-sclerosis/

Lots more on the web.

I'm a cancer patient and can't get it legally in my state yet, even though med mj is legalized for 2 years. Cannabidiol has antitumor properties. I am lobbying in my state now to get moving on mm and get the dispensaries up and going.

[Mnpaul]

172. I knew we were screwed

when Billy Tauzin was welcomed with open arms at the WH while the single payer folks were told to take a hike.

[Doctor_J]

392. but it's all Lieberman's fault

He forced the president to give big insurance 600 billion dollars a year

[pnwmom]

590. The National Health system in the UK has a formulary.

So does Canada's. So does Medicare and Medicaid's.

This has nothing to do with the ACA, except that his broker gave him false information about his choices. The ACA requires all insurance companies, on or off the exchange, to accept all patients, including those with preexisting conditions. Each insurer has its own formulary, so he should be comparing all the plans offered in his state to see if any of them list the particular drug his wife needs.

[truebrit71]

591. On the NHS if you need meds, you get meds.

Very simple.

[pnwmom]

592. You get meds if they're listed as available on the formulary.

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

The British National Formulary (BNF)[1][2][3][4][5][6] is a pharmaceutical reference book that contains a wide spectrum of information and advice on prescribing and pharmacology, along with specific facts and details about many medicines available on the National Health Service (NHS), including indication(s), contraindications, side effects, doses, legal classification, names and prices of available proprietary and generic formulations, and any other notable points.[7] Though it is a national formulary, it nevertheless also includes entries for some medicines which are not available under the NHS and must be prescribed and/or bought privately (such as alprazolam tablets or minoxidil solution). A symbol clearly denotes such drugs in their entry.

[truebrit71]

595. I have two elderly parents that use the NHS all the time.

When they need meds, they get meds. No hoops to jump through...Doctor prescribes them, they take them. No muss, no fuss.


Of course the conservative arseholes in power are trying to destroy the NHS anyway they can, so I'm sure there will be "market-based improvements" brought to bear...but hopefully they will be removed from power next year...

[pnwmom]

596. That's because the doctors are choosing medicines off the formulary.

The same as doctors here do with Medicare patients, whose choices are also limited by a formulary.

http://en.wikipedia.org/wiki/Formulary_(pharmacy)

United Kingdom[edit]

In the UK, the National Health Service (NHS) provides publicly funded universal health care, financed by national health insurance. Here, formularies exist to specify which drugs are available on the NHS. The two main reference sources providing this information are the British National Formulary (BNF) and the Drug Tariff. There is a section in the Drug Tariff, known unofficially as the “Blacklist”, detailing medicines which are not to be prescribed under the NHS and must be paid for privately by the patient.

In addition to this, local NHS Trusts, including Hospital Trusts and Primary Care Trusts (PCTs), produce their own lists of medicines deemed preferable for prescribing within their locality or organisation; such lists are usually a subset of the more comprehensive BNF. These formularies are not absolutely binding, and physicians may prescribe a non-formulary medicine if they consider it necessary and justifiable. Often, these local formularies are shared between a PCT and hospitals within that PCT's jurisdiction, in order to facilitate the procedure of transferring a patient from primary care to secondary care, thus causing fewer “interfacing” issues in the process.

As in the United States, NHS trusts actively encourage generic prescribing, in order to save more of the budget allocated to them by their Strategic Health Authority, and ultimately, the Department of Health.

[OwnedByCats]

608. Exactly

The NHS runs perfectly compared to these insurance companies that make everything complicated, all in aid to screw you.

[HuckleB]

609. I've been told otherwise by more than one Brit.

[Spider Jerusalem]

682. Only if it's been approved by NICE

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

[CaliforniaPeggy]

2. Anger IS a gift, my dear Will, and one you use most effectively.

K&R for this most excellent rant.

[uppityperson]

207. "fuck you mr president you piece of shit used car salesman" is an "excellent rant"?

I do hope that is not what you meant.

[CaliforniaPeggy]

208. And if I did?

I'm just agreeing with Will.

[uppityperson]

235. If you did, it makes me sad to see 2 long term duers like you and he think that is ok

Without that, no problem

[CaliforniaPeggy]

238. I regret that you're sad. But I do stand with Will on this topic. n/t

[uppityperson]

240. I wish we'd gotten single payer, but can not understand calling him that. Or putting all the blame

on Pres Obama as it is not all hos. Blame congress, ins companies, and even Will for not checking to see if it was covered. It sucks, but to rant at Obama that way? bah

Best wishes to all with their healthcare, and insuruance companies are legalized gambling out to make a profit.

[JEB]

283. Miserable fucking crap shoot dealing with Insurance vultures.

Death and agony are their stock in trade. Fuck'em all.

[magical thyme]

301. NH does not offer many options for insurance

it's Anthem or nothing, iirc.

[truedelphi]

369. Look. Obama was so pathetic on this issue that even Jon Stewart called him out.

Mid August the summer of 2009.

Stewart: So a university student at U of Colorado Boulder, asks the President about public option, and the student seems to have the idea that public option is related to socialism or being a commie.

Does Obama take a moment to educate the young man. No instead, he apologizes for the existence of public option by saying (I am paraphrasing) 'Public option is but one tool in an entire tool box of options that Congress can employ. But since I am the President, and I am part of the Executive Branch of the US government, the separation of the three branches of government means I must bow out of the discussion until Congress has put its finishing touches on the piece of legislation that they re putting together.'
#### End of Stewart related material


Then we all come to find that while Obama is claiming his lack of using the bully pulpit for the public option, his own Chief of Staff, one Rahm Emanuel, was meeting with Liz Fowler to put together everything that the Big CEO types from, Big Pharma and Big Insurance wanted.

What is going on right now inside America's Body Politic is that people have had it. Over the last week, I have been tabling on an local issue, unrelated to party politics, and what I am hearing again and again is "Sorry but I quit voting."

Most people will just give a grin and giggle and say, "you know," when I ask why they won't vote in June.

But some people articulated that they see no real reason to vote in a rigged system. One man spent some ten minutes tracing his life as a voter, concluding with, "Well in 2012 they told me they were the lesser of Two Evils, and I kept hearing a voice in my head say, 'Lesser of two evils is still evil.'"

I concur with that man. If there is no one in Washington or in a leadership position in either party that cares about reforming politics, outside of maybe Bernie Sanders, or Liz Warren, with the rest of them being whores to Big Corporations, then why should I give a rat's ass in hell about the Democratic party?

[uppityperson]

370. So you agree President Obama is a "piece of shit used-car salesman" deserving "fuck you" on DU?

Edited to remove un needed snark with apologies.

[truedelphi]

379. Thoe were not my words,

So don't put them in my mouth.

But I did say that this whole situation of having two parties bought and paid for by Big money is pathetic.

And it is also as one other poster pointed out here, Fascism.

That "F" word is a far greater indictment than the swear words. You can be offended that angry people are using "anger words," or you can be offended that we have devolved as a meaningful republic with free elections, and are now ruled by whores to Big Business, it is your choice. I know what I am offended by.

[uppityperson]

382. My apologies, I edited to remove the unneeded snark. Yes, there are a hell of a lot of problems,

but cursing out the president and calling him a used car salesman doe snot address the issues. And isn't needed on DU to discuss wtf is going on and wtf to do about it.

Again, my apologies.

[hfojvt]

559. because greater of two evils

is still greater.

The conservatives in this country, the Koch billionaires are still out there electing Republicans and pulling the Republican party always to the right, to the right, to the right.

I am sure they will be happy if we stop resisting that.

[Enthusiast]

503. They should have pushed for single payer with all their might.

When the President took office he had a MASSIVE mandate.

Instead the President said that single payer was a bridge too far and would be "too expensive". Well, he knew better. He knew damned well that single payer would have been substantially cheaper but it would lock out the for-profit vulture killers.

President Obama deserves considerable blame.

[red dog 1]

706. + 1

President Obama should have at least TRIED to get a single-payer health plan; but he didn't.


As far as the OP:
I agree with : "Fuck you, insurance industry"

But I don't agree with:"Fuck you, Mr President, you piece of shit used-car salesman."


I posted an OP on the possibility of changing the ACA into either single payer or a universal health care plan
"Can Obamacare be changed to make it a single payer health plan?"
http://www.democraticunderground.com/10024670957/

[Enthusiast]

708. Thanks, red dog 1.

Somehow, the ACA allows individual states to enact a single payer system as Vermont has. I believe California is trending that way also.

We must have single payer now! There are far to many of us suffering because of the greed factor.

[Scuba]

517. No, the insurance companies are not legalized gambling, they're mass murderers for profit.

[kelliekat44]

532. Sorry for your situation and sorry that you feel that way about the President. But the blame goes

the insurance and pharma-industrial-complex in my opinion. It is all so much bigger than one President. I believe an appeal is in order, first , and than a reasonable complaint to the President conveying what you have learned that I am certain he has no idea that this is happening We are in the first stages of trying to make the ACA really work for us all. It seems a bit unfair that the criticism should be so unforgiving at this point. What is this really about?

[uppityperson]

569. Hi, did you mean to reply to Will?

[brush]

476. Pitt has done that before

He ranted about the President using the injured Sargent Cory Remsburg as a prop during the State of the Union speech.

He totally missed the point that the President was trying to make — that the kind of injuries the solder suffered were the results of endless wars with endless deployments. The President called for the end of our constant war footing.

It was the first time in my lifetime that a sitting president made an anti-war remark.

It was extraordinary but, somehow it was too subtle for Pitt and he posted an even worse rant against Obama. Makes you wonder about people who fly off the handle with mis-targeted anger — especially the ones with supposed gravitas.

[Cha]

479. "Too subtle for Pitt.." that's about it. Went right over his head which was

easy to do because he was down there working on the worst angle he could possibly come up with.

[JI7]

480. nothing was missed, Pitt is just playing to a certain crowd looking to be popular

[brush]

481. Guess it's the Obama haters. nt

[Kahuna]

498. Yep and yep!

nt

[quakerboy]

613. Damn him for "playing" at having a real life problem.

Maybe he doesn't even have a wife. Or if he does, he probably doesn't even really care about whether she has access to medication that she needs. Because he's just playing at being a living, caring person with a family.

Its amazing to see the heartlessness here, from people claiming to be democrats or progressives. Care about our fellow man? Not if it might impede our ability to praise the political figure of our choosing!

[Jakes Progress]

616. He'd be okay

if he just wrapped himself up in Obama-Glo and ignored his wife's pain. Blind adoration is a great salve.

[Cha]

455. It's an "excellent rant" to those who don't care that his rage is misplaced.. it would be a

more cognizant rant if he were actually throwing his ugly insults at whomever was actually causing the problems with his wife's meds.

[sobenji]

525. THIS

How true. Because the millions of people who can now get insurance don't matter because his wife's medicine isn't covered.

blame express scripts, blame optum RX, blame United healthcare, blame anthem, blame big Pharma, blame Lieberman (fuck him), blame Bayh. Blame everybody.

But the president did what he could to get as many people insurance as he could. Is it perfect? No. Is it a good start? Yes.

Go fight for the coverage. There's lots of good advice in this thread that tells you what to do. Start with the insurance company, go to the Department of Insurance, find a lawyer friend who can help write letters. But fuck the president because you didn't get coverage for a drug? Nope.

[truebrit71]

564. A-fucking-men! Well said!

Sick of the compassion-free, toe-the-liners around here..

[kath]

582. it was a great post.

Too bad it was hidden.

[truebrit71]

585. The apologists can't handle the truth I guess...

..

And boy there's a lot of them around it seems...

[quakerboy]

615. This

after reading the first few responses, a fairly equivalent but less well spoken rant was in my mind. Everyone should take the time to unhide this. And the fact a jury hid it, over all the other crap ive seen fly by unhidden, says some ugly things about DU.

And a hearty fuck you to every person posting like a heartless Republican on this thread. Democrats have compassion. You do not. You have outed yourself to anyone who is paying any attention, though you will likely skate by for now because you are pretending to be aligned with Democrats.

[truebrit71]

618. I too was amazed that it was hidden...

...especially looking at some other posts that were left alone...although it was fairly obvious by some of the responses that the apologists are well-coordinated..

[Cha]

635. Thank You, sobenji!

[Cha]

638. Oh My, that post that was hidden addressed to you,

was a nasty piece of ignorant work.

[Auntie Bush]

711. Well said! +100

[Autumn]

4. No. How could those bastards do that?

can you look into another plan that might cover it?

[WilliamPitt]

8. Heh.

There are ten different health insurance companies in NH. According to the independent (family friend, ally) insurance adjuster I spoke to at length this afternoon, pursuing coverage with any of them would be a waste of time. Why? Because - according to dude - the whole "You cannot deny coverage to people with pre-existing conditions" thing only applies to insurance companies within the ACA network. You heard all that shit about "Grandfathering." Well, this is that, and all of them will turn us down because they still can.

I am in the process of running down the facts of the matter, but family friend and ally was confident enough to basically tell us not to bother.

So yeah, that, too.

[Autumn]

10. Those mother fuckers covered all the bases didn't they.

I'm so sorry Will.

[Nye Bevan]

53. I'm pretty sure that is not true.

Any insurer selling individual health plans (whether on or off the exchange) in your county cannot discriminate based upon pre-existing conditions. (However, grandfathered plans that are not being sold anymore will not be offered to anyone, whether or not they are in good health). Here in CT we have an off-exchange policy which I bought because all of the exchange policies offered only very narrow networks which excluded most of our doctors. Approval was immediate and without any questions about health. (The off-exchange policies are not eligible for subsidies but are still guaranteed issue).

For example, if you go to Anthem.com and enter your zip code to browse individual health insurance policies, you will get check boxes to choose between "Marketplace" and "off-Marketplace" plans. The "off-Marketplace" plans are not in the ACA network but are still guaranteed issue.

As far as the drugs go, yes, this is frustrating, but you need to persevere. Have every doctor you can write a letter explaining why this drug is essential. Make copies of previous prescriptions to show that your wife has been using this drug for a long time. And send all of this documentation with a polite but insistent appeal that this drug be covered. If the appeal is turned down, immediately appeal to the next level. If you have already reached the top level, immediately file a complaint with your state's health insurance department. I have needed to do this a few times over the years here in CT and not once have I ever failed to eventually get coverage of whatever I wanted. The impression I get is that their business model is to routinely deny coverage secure in the knowledge that many people will just give up, but the persistent complainers who keep escalating their complaints eventually get what they want. In particular, going to the state insurance department always seems to suddenly make them take you much more seriously.

[QuestForSense]

96. Excellent advice.

You can't even pay people to give you advice that is half this good.

[crim son]

649. It's super advice but, dammit,

none of it should be necessary.

[Whisp]

115. ''with a polite but insistent appeal that this drug be covered.''

that ain't gonna happen.

[Lex]

127. " not once have I ever failed to eventually get coverage "

so it has worked

[Whisp]

132. I meant the polite part ain't gonna happen.

[Lex]

143. Oh, I see. Yeah, probably.

Persistence is key. And being the squeaky wheel.

[ConservativeDemocrat]

170. Ranting on the DU about how awful Obama is won't change anything

Hopefully William Pitt will realize that for once.

- C.D. Proud Member of the Reality Based Community

[Lex]

174. It's not like Obama is happy

about people not being able to get their preferred drug for a chronic health issue.

[Whisp]

279. Some think he is. They truly believe it makes him happy that people suffer

because of what they claim he did to them.

There is a post here somewhere with an animated pic of Obama laughing (apprently at the OPs problems).

now that is a piece of shit thing to say.

[ohheckyeah]

456. Unless, of course,

the preferred drug for a chronic health issue is marijuana.

[Jesus Malverde]

486. Great catch!...nt

[magical thyme]

307. it's already gotten him some sound advice

as well as emotional support and a load off his chest.

All of which are good things.

[ConservativeDemocrat]

633. True enough, but I think he could have gotten the same without screaming

Especially about formularies, which all medical systems have, even the vaunted single-payer.

- C.D. Proud Member of the Reality Based Community

[magical thyme]

637. I agree he could have gotten it without the screaming

however, I'm willing to cut people slack in the first wave of combined panic and anger when they discover something really, really bad regarding somebody really, really important to them. And when you're a writer by profession, then the screaming comes out in writing.

Certainly I refrain from blaming them or calling them foolish for making a poor choice, when choices were made under tight time constraints and were set up by the sales people to be as inscrutable as possible.

The formularies, as mentioned in several posts above, are not necessarily available for review until *after* you sign up, which makes it impossible to choose your insurer based on the formulary.

Other insurance industry "fine print" problems are surfacing, and will continue to surface. For example, I just posted about a problem with access to cancer centers. If anybody bothers to read the linked article (and of course many won't, they'll just shoot from the hip) it looks like the issue is going to be examined (and hopefully addressed) next year.

[Doctor_J]

395. we should not have to spend our lives begging insurance companies to

do what they are supposed to do. Do you comprehend how moronic that is?

[Whisp]

403. what I think is moronic is

the poster took the word of some 'personal friend' schmuck that there is nothing else to be done.

A lot of information, just in this thread, that says there is a Lot to be learned and done. He should do the damn homework instead of having another ridiculous tantrum. Tantrums will not do anything for the situation.

[woo me with science]

407. And cruel.

What this thread screams for us, yet again, is the actual level of compassion of the corporate Third Way - its utter contempt for the people it pretends to want to represent.

Corporate rule, whether Republican or Democratic, is all about the bottom line. It is about slick marketing of policies that profit the One Percent, rather than actually seeking to serve the needs of human beings. Corporatism is, by definition, about profit and *never* about human beings. No matter how many pretty promises we hear from corporatists during election years, the contempt you see in this thread is the actual level of compassion that will be offered when actual human beings are harmed by corporate policy.

[ctsnowman]

508. Cruel

is the right word.

[ohheckyeah]

458. You only think that

because you aren't a good little citizen/consumer.

[NCTraveler]

526. "do what they are supposed to do."

They are doing what they are suppose to be doing. Making profits. And they were just given a gift. Not debating you as I pretty much agree with you, just wanted to add what their main goal is. Profits. Their job is to care for investors, not provide healthcare.

[Doctor_J]

529. We got our annual benefits pitch from the insurance rep

and as I sat listening to her tell us all of the wonderful features of company's offering (my annual deductibles this year went from $500 to $8300), that thought kept rolling through my mind. Her job is selling insurance and making money for herself and her CEO. It has nothing to do with keeping me healthy.

[NCTraveler]

533. "It has nothing to do with keeping me healthy."

Truly sorry about your deductible. You are absolutely correct. She was there to sell you health insurance, not health care.

[sabrina 1]

213. While your advice is good advice, considering the system we have, it is truly sad that sick people

have to work so hard to stay alive in this country. While Will can probably do all this, there are untold numbers of people who do not even know how to use a computer, or have anyone to help them wade through all this. And to have to PAY to be so abused, is unconscionable.

Health Care should be a right, but here people are just commodities and the rights go to Big Pharma and the Private Insurance Corps who mostly wrote this legislation. Their right to profit, trumps OUR right to live. It's better that people understand how it is, rather than remain hopeful that there is someone within this system who actually cares about them.

Wendell Potter, Whistle Blower described it perfectly when he told how shocked he was to see Americans lining up for a Third World charity organization, then operating here, in the US. Of seeing Americans being treated in Animal Stalls, desperate for care they could not afford. It touched him enough to go back to his HC Corp and show them his photos, hoping to get a reaction similar to his own very human reaction.

Instead, when he asked them what they saw, what they thought of it the response was 'More Customers'. But how, they had no money which is why they were there?

Now we know. Privatize Medicaid, force everyone to buy HC, if the can't afford it, the Health Ins Corps get it from Medicaid instead of that money going directly to the hospitals and doctors.

As that Public Fund, passes through their greedy hands, 20% or more is pocked by them.

What a scheme, if only we all could pull off something like this.

[Nye Bevan]

236. I'm one of the more pro-free market, pro-capitalism DUers

but I entirely agree that it is a monstrosity that people should be forced to jump through these hoops to get treatment for diseases. Health care is not a commodity that should be managed by the pursuit of profits.

[sabrina 1]

449. Thank you! I support the free Market also, but not when it is abused, and imo, HC should

never have allowed to be 'for profit'. There was just too much room for abuse. Or at least there should have been an option for National HC.

[questionseverything]

250. insurance companies will when forced cover what is in the contract

it will do no good to complain to state ins board if his contract denies it

(and you know that)

[Nye Bevan]

253. On three occasions my insurer has denied coverage for a drug for a family member.

On two of these occasions when I used the insurer's appeal process the decision was reversed. On the other occasion the decision (not to cover) was upheld but then when I complained to the state insurance department they agreed to cover it.

[steve2470]

257. the squeaking wheel definitely gets the grease

A company will only refuse you if it really screws them over long-term and/or hurts their public image. Health insurance management looks awfully cold-hearted denying needed meds for people, especially children, the disabled or the elderly.

[questionseverything]

263. are you saying the ins paid for meds not covered in contract?

now if you were arguing over what is "reasonable and customary" then yes there is contract language that state ins department could help with

but if you are saying you got something covered that was not in contract......I call bs

without knowing what will has in his contract's language, it is impossible to tell

[Nye Bevan]

273. My policies (and I believe most policies) have "non-formulary exception" provisions

with this kind of language:

Non-formulary exception process

The non-formulary exception process provides physicians and members with access to non-formulary drugs and facilitates prescription drug coverage of medically necessary, non-formulary drugs as determined by the prescribing practitioner.
Patients can also have a non-formulary drug without invoking the exception process anytime by paying full price for the drug if the prescribing provider deems the non-formulary drug not medically necessary, but agrees to prescribe the drug due to patient demand.
The prescribing practitioner makes the final decision regarding what drug is appropriate for the member. Non-formulary drugs should be used only if the patient fails to respond to formulary drug therapy, has an adverse reaction to formulary drug, or has other special circumstances requiring the use of a non-formulary drug.

[questionseverything]

280. with that language he probably has a case

as you described....and as I pointed out the ins would pay only if the proper language was in contract

we still do not know what will's contract says

maybe you would like to field this question of mine////////////////////

http://www.bcbsil.com/PDF/rx/rx_list_std_il.pdf

Specialty drugs
Specialty drugs are used in the treatment of medical conditions such as hepatitis, hemophilia, multiple sclerosis
and rheumatoid arthritis. Specialty drugs may be oral, topical or injectable medications that can either be
self-administered or administered by a health care professional. For a current list of specialty medications,
visit myprime.com or bcbsil.com and log in to Blue Access for Members.
Note that some drug classes may be excluded by some plans and therefore may not be covered under your
pharmacy benefit. Your plan may have a different coverage level for self-administered specialty drugs. If you
have questions about your coverage for specialty medications or your prescription drug benefit, call the
number on the back of your ID card.
////////////////////////////////////////////////////////

how do I look it up before I buy?

I have to be a member before I can see the list

cimzia is what I am looking for

/////////////////////////////////////////////

cimzia is about 1600 bucks a month retail so the 700/month cap would screw us over too

[Nye Bevan]

344. Yeah, they are (deliberately, I think) vague about coverage prior to you taking out the policy.

Which sucks and is frustrating. I looked up cimzia on my plan and all it told me was that pre-approval was required (it would not even give a price). For this drug, however, the manufacturer's website seems quite helpful (go to http://www.cimzia.com/cimplicity/patients.aspx). They have a copay savings program where they help you verify insurance coverage and you get a savings card which (they claim) resulted in no out-of-pocket costs for 97% of the participants in 2013. It sounds like what they do is help walk you through the approval process to help you get the drug approved and then absorb any deductible or copay themselves, just accepting whatever the insurance company pays them, with you getting the drug for no out-of-pocket cost. You should definitely look into this; I have used a similar manufacturer's program with another drug and the savings can be enormous. Good luck!

[questionseverything]

575. yes some drug companies have good plans to help

but that really is not the point being discussed here in this op is it?

will was told it was his fault for not knowing what is covered, I think you and I have just shown this is not necessarily true

so what it boils down to is even with insurance "we the people" are still going to be left to the mercy of insurance companies and big pharma.....this is what will's op clearly points to, emotions aside

[Ms. Toad]

604. I have never had an insurance company refuse to provide the formulary

or the doctor list prior to plan purchase. Those are two things I always check, because of long term relationships with doctors - and very costly meds.

Specialty drugs are relatively new - typically they are biologics. But they have nothing to do with the ACA. I'be been fighting that particular dragon for a around 5 years now.

[questionseverything]

606. what i posted is the formulary

but it gives no answers on specialty drugs....deliberately vague is probably the closest to the truth


and the reason it is related to aca is the aca did nothing to prevent the spiraling of med costs......cost containment should of been the first issue addressed

[Ms. Toad]

617. From the first two pages of the formulary at the link you posted:

Specialty drugs:
tobramycin inhal soln (Tobi – brand is NF)
INCIVEK
PEGASYS
ribavirin (Copegus, Rebetol – brands are NF)
VICTRELIS
FUZEON

- and many more in the rest of the list.

I don't see your particular specialty drug - so you should call them with the specific name of the plan you are considering and ask them if it is covered. It appears from they way they have the formulary set out that some specialty drugs are covered on all plans, and others are not uniformly covered - so you will have to ask about a drug which is not uniformly covered. If you are taking a specialty drug, it is probably worth it to make a phone call.

[questionseverything]

620. if you have been reading what will has written

he had asked first thing if his wife's drug was covered,,,,,,ins says yes with a very simple procedure

that turned out to be untrue as she has been rejected twice

if you have fought as many successful appeals as you say you have you know, if it is not in the language of contract it is not covered

no verbal commitment matters

now in will's case I am sure his wife's needs will be met , he is fairly high profile but again I ask, what about those that are not high profile people?

what about those that do not have the time ,energy or means to fight big insurance?

and one more thing while I am at it........we do not know what will's spouses meds cost, some have suggested it is a new pill form of specialty drug that costs 4600 bucks a month....if that is true the economic model for aca is no way sustainable

some things are just too important to leave to a profit driven industry

[Ms. Toad]

624. I have won plenty of appeals for things which were not in the language of the contract.

But - before starting buying a new plan, I would have gotten the details in writing. It sounds like a step therapy drug - and from what he has said, it sounds to me like his doctor's office doesn't have a clue how to complete the proper forms.

The reason I say that is because one of the most medically competent doctors treating my spouse and daughter has zero clue about how to get approval for a step therapy drug. He started out by telling her that insurance probably wouldn't cover it - since he hadn't been successful in getting approval for anyone else. It is actually a very simple procedure - clearly described in the certificate of coverage (and explained to me over the phone). You have to get the doctor to certify that one of multiple other therapies have been tried, and are not suitable, and then it will be covered - because for most people there are better, cheaper, options which they want you to try first.

In our case, it took about a month, with the doctor repeatedly telling my spouse that they had appealed and been denied, and the insurance company repeatedly telling me they had no record of an appeal - and that it was a simple procedure to get step therapy approved.

What it came down to when I unwound it all was that the doctor was clueless, and my spouse did not give them the address/phone/fax for step therapy approval which I had told her to give them, because she assumed they should know how to handle insurance. They had been faxing a regular prescription to the regular prescription number, and having it rejected. They called the same division, who gave them other non-step alternatives, without mentioning that it was a step therapy drug. I was finally able to have the insurance company open a case for the step therapy. That allowed them to contact the doctor directly and request the documentation, and within a week we had the meds.

If it had been my doctor, it would have been straightened out in 2 days max - but this is one of very few doctors I "let" family members handle on their own, since (generally) he doesn't handle the family diseases where where someone with a mind adapted to handle medical matters is crucial (lots of rare/complex diseases in our family).

But making the insurance companies behave has nothing to do with being high profile. It does have to do with being persistent, with knowing your plan, and with having doctors who are either advocates by nature - or who are willing to advocate if you lead the way.

As far as the ACA being sustainable - the premiums are based on averaging the high cost of Will's wife's costs (and my daughter's costs) with the more typical costs that most of us have. They are sustainable - not ideal - but sustainable because that is how shared costs work (either insurance or single payer). I believe the average annual spend per person (including for those very expensive people) is around $5000. They would, of course, be both cheaper and even more sustainable if the insurance middleman was taken out of the picture.

[questionseverything]

640. extra ordinary claims require proof

I think this is one of those claims

you said,

I have won plenty of appeals for things which were not in the language of the contract./////////////////

so I would love to see the documentation

[Aerows]

646. Half the people in this thread defending the ACA

live in either Canada or Australia, and thus don't have a fucking clue how screwed up health care is here. They are just defending Obama because he's Obama. They have absolutely no basis for comparison. If you ask them individually, they will admit it, but publicly, it's all Obama all of the time. Understand what you are dealing with - people that will tell you that the ACA rocks while they have never in their life gotten sick and then had to deal with hospital bills.

[Ms. Toad]

648. Right. Like I am going to post my medical documentation on the internet.

I'll give you enough details of a couple of examples sp that you can at least verify the condition and the difficulty of getting coverage at the time.

I have VTOS (upper extremity DVT), which dates to 1988. The first time I spent a month in the hospital because that was the only option for stabilizing on anticoagulation therapy before being discharged on warfarin. - normally the process of balancing the two anti-coagulation medications takes 5-7 days; my body was stubborn. The second flare, 1998, low molecular weight heparin (Lovenox) was developed - but was only approved for clot prevention in connection with surgery - not as a treatment for clotting disorders. The choice was spending several days in the hospital, or convincing the insurance company to cover outpatient use of Lovenox. With my doctor's assistance, they insurance companies were convinced to allow me the (then) experimental treatment.

Here's a 1999 article about the early reported use of it for outpatient treatment: Savage KJ, Wells PS, Schulz V, Goudie D, Morrow B, Cruickshank M, et al. "Out-patient use of low molecular weight heparin (dalteparin) for the treatment of deep vein thrombosis of the upper extremity." Thromb Haemost. 1999;82:1008–10. There was also an ER episode around the same time "ripped from the headlines' as another show likes to say, in which the more common outcome - denial of coverage - was the outcome. That study of 46 patients was published almost a year and a half after my insurance company was convinced to allow me to use it for that condition as an outpatient. And, a 1999 article which references 12/31/1998 FDA approval for marketing the use of enoxaparin for outpatient use for treatment of uncomplicated DVT - 7 months after my insurance company was convinced to pay for it.

Here is a link to a separate mention of my first rib resection which was done to treat the same problem more recently - next to last paragraph. I obviously must have planted it contemplating just this conversation. Feel free to confirm that first rib resection is the current favored treatment for VTOS.

Another minor victory in the same time frame - the pathology costs relating to removing a mole displaying pre-cancerous traits were covered, but the excision was denied. They routinely denied all mole removal "cosmetic surgery." I didn't have to get the doctors involved in that one - I just challenged them about whether they denied coverage for the surgical removal of breast tissue in to examine the tissue associated with apparently pre-cancerous changes as cosmetic breast reduction surgery. Kind of surprised they bought that one as easily as they did, but they did.

Finally, if you have had many encounters with surgery and insurance, you are aware (or if not you can easily verify) that anesthesiologists are entities unto themselves - and fairly frequently not covered by the same insurance policies as the hospitals in which they work. I had an emergency appendectomy, and the anesthesiologists were considered "out of network," even though the hospital was "in network." The closest "in network" anesthesiologists were more than 50 miles away - and all out of network care required advance approval. Despite not having advance approval, they ultimately granted my appeal because of the emergency nature of the surgery, combined with the lack of disclosure by the hospital that they were using an anesthesia team which was out of network. (Here's an article) which specifically mentions this issue with anesthesiologists

Just 3 of the more generic examples of the many appeals I have won. Sorry - I'm not posting documentation, but you should be able to at least verify that they are the kind of problems which routinely crop up with insurance that are either prohibited by the policy, or beyond the language of the policy.

[questionseverything]

657. ok since you took the time for all that i will try and address it

i still do not think you won anything outside the scope of your language

the first example is closest since the drug you wanted was experimental but the treatment you and your doc wanted saved them a week plus of cost for in patient hospital charges

the second example, if pre cancerous was well with in your language to be covered

the anesthesiologists example rings a bell with me because I had to fight insurance companies for same except we had no network to bind us but ins denied it over and over, first saying it was included in surgeons bill, then saying that they had already paid for it (when actually they had just paid for the supplies), then they said the hospital billed them wrong..... so while I had insurance gal on cell phone I drove to the hospital went to billing clerk handed her phone after explaining to clerk the problem was her....she ripped that insurance gal a new one (in a very polite professional way) and when she got off phone it was covered

/////////////////////////////////////

our entire convo here is sad, what you are describing is how insurance deliberately denies what they rightly should pay (imagine how many people do not fight them and just pay it)

I am not sure why you are defending this system, I guess if you think it's good enough for you and yours you have a right to think that way....I do not agree

out of curiosity, with all your families medical issues how were you buying insurance before the aca? was it thru an employer?

because my house does not have anywhr near the medical problems you have described and we were priced out long ago

[Ms. Toad]

663. All three are outside the language of the policy -

The first was not covered. It was not part of the formulary, nor part of the medical coverage. One of the articles I linked you to discussed how insurance companies dealt with it at the time (pretty much not at all). And - if you look for articles at the time, you will find it was routinely denied - even though it saved the insurance company a considerable amount of money. The stupidity of that is why it was popularized on at least one medical drama within a year of my experience with it.

The second was clearly, by the policy, excluded as cosmetic surgery. It was a ridiculous exclusion, but it was an exclusion.

As to the third - that is the closest to being covered in the language of the policy, in that there was an appeal process to petition to have out of network care treated as in-network. There's plenty more.

And, as I said, those are three which are either relatively generic and which I can point to historical or other outside references to provide some support (or, in the first instance, one I have mentioned on DU before).

As for coverage - it has been a variety of coverage over the years, made more difficult because I have a same gender spouse who has not been able to work for a decade (early onset Alzheimers).

We cannot buy insurance on the open market - prior to the ACA, it would have $15,000 - $20,000/year for my daughter alone, and far more for me based on age. Early in her life she was covered by Medicaid - during a period when my income was minimal and, because our marriage is not recognized, neither of us were eligible to be covered under my spouse's policy.

I had private insurance for a while, the company went out of business, and I discovered I was uninsurable by anyone else. I weighed my options and went with a succession of short term policies (~200/year for catastrophic coverage and no pre-existing coverage), on the theory that I was healthy but for this rare pre-existing condition and the worst that could happen was that my pre-existing condition would act up, I'd have one big splash when I was hospitalized, and then I'd have to buy into the open enrollment at several times the cost my daughter would have to pay.

Since then (99+), I have had coverage through work - sometimes at the cost of my emotional health - staying at my most recent position far longer than it was emotionally healthy because it was the only option for covering my entire family. Our options were - put up with an emotionally unhealthy job, or pay whatever the insurance company felt like charging us under COBRA, then the HIPAA conversion to individual coverage.

I recently switched jobs - taking a 60% pay cut (and worse health care benefits) because the job is better for me emotionally and still provides coverage for all of us.

But my daughter would have been off my health insurance 4 years ago because she cannot manage a full time load at school or work, and we would have had to get her on disabilitiy, but for the ACA. She now has the option, because of the ACA, to be a starving artist and not have to work toward a job she hates because it is the only way she can survive. Her billed medical costs are $60,000 in a good year. She literally cannot survive without the ACA.

So I have very little patience with people with similarly devastating conditions, who don't pay enough attention to take advantage of the system and then blast the system which is far from perfect ** but which offers life to people like Will's wife and my daughter. Because blasting it gives ammunition to those who want to destroy it and replace it with nothing.

What the ACA offers is worlds better than what we had before. *All* we got in the last major reform (~1996) was HIPAA individual policies (with unlimited premiums) available only to those who had a job and left it, and *all* we got the time before that (~1980) was COBRA - 18 month policies again, unlimited premiums and only available to those leaving jobs where they had had health insurance. My daughter can't live for another decade and a half waiting for perfection, just because the major reform we got this time isn't anywhere near perfect.

[questionseverything]

697. maybe this exchange will help you understand

the language was there.....


are you saying the ins paid for meds not covered in contract?





now if you were arguing over what is "reasonable and customary" then yes there is contract language that state ins department could help with

but if you are saying you got something covered that was not in contract......I call bs

without knowing what will has in his contract's language, it is impossible to tell

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Response to questionseverything (Reply #263)

Tue Mar 18, 2014, 09:20 PM

Star Member Nye Bevan (14,816 posts)

273. My policies (and I believe most policies) have "non-formulary exception" provisions





with this kind of language:



Non-formulary exception process

The non-formulary exception process provides physicians and members with access to non-formulary drugs and facilitates prescription drug coverage of medically necessary, non-formulary drugs as determined by the prescribing practitioner.
Patients can also have a non-formulary drug without invoking the exception process anytime by paying full price for the drug if the prescribing provider deems the non-formulary drug not medically necessary, but agrees to prescribe the drug due to patient demand.
The prescribing practitioner makes the final decision regarding what drug is appropriate for the member. Non-formulary drugs should be used only if the patient fails to respond to formulary drug therapy, has an adverse reaction to formulary drug, or has other special circumstances requiring the use of a non-formulary drug.
////////////////////////////////////

I would like to address this quote of yours..

Because blasting it gives ammunition to those who want to destroy it and replace it with nothing. //////////////////////

pointing out problems is the only way to fix them.....I have never seen any1 on du say they wanted to repeal aca only that we want it expanded and costs lowered

[Ms. Toad]

702. Yes. The insurance company paid for meds not in the contract.

Lovenox (subcutaneous heparin) was excluded from coverage for any use other than pre-treatment for surgery. I gave you several links which described what was going on at the time. The vast majority of people who tried to obtain coverage (under any policy) to use it to treat DVT were denied because it was excluded from coverage. At least one of the articles I linked to mentioned this and, as I said, the TV show ER had an episode within a year of my encounter with the standard outcome - the coverage was denied and the patient had to be hospitalized for 5-10 days (standard treatment at the time) when it would have been a whole lot cheaper to pay ~$500 (at the time) for a Lovenox prescription.

My doctors were successful in advocating for me to get it covered, even though it was excluded from coverage.

This was before formularies played a significant role - so it wasn't a matter of getting an exception to the formulary. It was also, under my plan, classified as medical care (rather than prescription).in connection with a single permitted use. One of the articles I linked to mentioned this weird coverage split (prescription v. medical).

As to wanting to repeal the ACA - there are plenty of folks on DU who want to see it abolished. They want single payer, but in the mean time they want the ACA gone. And rants like the one which started this thread aren't helpful.

[bullsnarfle]

540. Connecticut??? Huh.

Come on down and try that in Florida, pal. This place is run by Gov. Voldemort and his minions. Remember him? He CEO'd a crooked health insurance company (like there is any other kind), walked away with a platinum parachute, and used the ill-gotten gains to buy the governorship. He and his cronies own this state. Letters and bitching will get you exactly SQUAT here, dude.

Others have said it on this site, and I will reiterate - Access to health insurance DOES NOT equal health care. You can pay, and pay, and pay, and when the time comes for insurance co. to pony up they just...don't pay. Hey, the doctors may be sympathetic, but they want their money, and if they can't get it from old Double Cross they will go after you. I mean, what are you going to do, hire a lawyer? Bwahahahahahaha...yeah, right.

[wordpix]

557. agree about going to state insurance agency---also go to your Congresscritters

If they're Dems, that is, they will act to help you.

If they're repukes, all bets are off

[thesquanderer]

92. You are not *required* to stay in a grandfathered plan.

As I understand it, for individual insurance purchasers (which it sounds like you are), grandfathering allows--but does not require--you to stay with a pre-ACA plan that you already have, if you like it better than getting a new ACA plan. Most people are probably better off with an ACA plan, but grandfathering is there for the rare exception, or for people who are just scared by the idea of changing to something new. I think you should definitely check into the ACA plans in your state right away and see what your options really are.

Obamacare is not forcing your old insurance company to deny you anything... they would have denied you the same thing before Obamacare existed. After all, grandfather means it's the same plan it was before Obamacare. But at least in theory, Obamacare gives you new, better options that you didn't have before. It's worth trying to find them.

[pnwmom]

324. Will, you have been grossly misinformed by your friend and ally.

We were also working with an independent, whose emails to us had boilerplate on them about having to get approved to get the insurance. I finally asked about this, and he acknowledged that the law was changing as of January 1, 2014 so that they would have to take every customer, without regard to preexisting conditions.

But their email boilerplate still had the false information after Jan. 1. We ended up buying through the exchange. But another option might be better for you -- just not with your uninformed friend.

http://www.nytimes.com/2013/10/26/your-money/health-insurance-options-arent-limited-to-obamacare-exchanges.html?_r=0

In general, health policies effective Jan. 1, whether sold on the exchanges or off, must comply with the Affordable Care Act. That means they have to offer the same menu of essential benefits, like drug coverage and maternity care, and can’t deny you coverage if you’re already sick. And, insurers who sell policies both on and off the exchanges must sell the same plan for the same price.


http://www.insure.com/articles/healthinsurance/buying-health-insurance-outside-exchange.html?WT.qs_osrc=fxb-182807210

Drug coverage

Drug coverage is yet another variable. You may find you have more options when it comes to drug coverage if you shop off-exchange. Like provider networks, health plans can limit the drugs that are covered, or reimburse more for generics than brand-names, or reimburse more for drugs you buy mail-order than from your local pharmacy.
If you have a health condition and use a particular drug, you should check that it's covered under the plan in which you want to enroll, whether that plan is on the exchange or off-exchange, Coleman advises.
Remember, too, he says, the cap on out-of-pocket expenses doesn't apply to drugs not on a health plan's list of covered medications.

[Nye Bevan]

349. Yes, the main thing to bear in mind is that there is no premium subsidy with an off-exchange plan.

But as you point out, the same rules apply to these plans in terms of guaranteed issue regardless of pre-existing conditions, no out of pocket costs for preventive care, and so on. And at least where I live, the off-exchange plans have vastly superior networks of doctors than the exchange plans.

[Zorra]

5. I repeat: I refuse to die until I have first danced on the mass grave of for profit health

insurance companies.

So very sorry for this massive injustice that has been done to your family, Will.

"Fascism should more properly be called corporatism because it is the merger of state and corporate power." -- Benito Mussolini

[truedelphi]

360. Can i join you in waiting for that dance

To begin?

[Enthusiast]

505. Me too.

[Brigid]

571. Me three.

But I fear it won't happen. I support ACA because -- and only because -- I want it to be a first step towards single payer. On its own, it is little more than a huge giveaway to the insurance companies and Big Pharma.

[Doctor_J]

530. Unfortunately I won't outlive Heritage Care

I have only 20 years or so to go, and it will be at least 50 before we decouple Big Insurance from the government, if at all.

[C_U_L8R]

6. This might help a little...

Heard of this but never tried it...
http://familywize.org

[loudsue]

7. More people need to be made aware that this can happen! This needs to go viral, because

if people are FORCED to buy insurance, then at least the insurance companies should be FORCED to cover keeping people healthy.

[Egnever]

9. You didnt check to see if an ongoing medication was covered before you signed up?

Seems pretty foolish.

[bvar22]

47. Blaming the victim is worse than foolish,

...and in this case it is beyond rude.

[Egnever]

74. LOL

being a victim is beyond foolish. Especially where your health is concerned.

If you need a medicine to live and you cant be bothered to check if it is covered by a plan you are thinking about purchasing you aren't a victim you are a fool.

That's like buying a Prius and claiming to be a victim when you cant tow your boat with it.

Much easier to blame others for your own indifference though isn't it?

[questionseverything]

234. ok i'll bite

http://www.bcbsil.com/PDF/rx/rx_list_std_il.pdf

Specialty drugs
Specialty drugs are used in the treatment of medical conditions such as hepatitis, hemophilia, multiple sclerosis
and rheumatoid arthritis. Specialty drugs may be oral, topical or injectable medications that can either be
self-administered or administered by a health care professional. For a current list of specialty medications,
visit myprime.com or bcbsil.com and log in to Blue Access for Members.
Note that some drug classes may be excluded by some plans and therefore may not be covered under your
pharmacy benefit. Your plan may have a different coverage level for self-administered specialty drugs. If you
have questions about your coverage for specialty medications or your prescription drug benefit, call the
number on the back of your ID card.
////////////////////////////////////////////////////////

how do I look it up before I buy?

I have to be a member before I can see the list

cimzia is what I am looking for

[steve2470]

245. I looked on that pdf file and can't find certolizumab pegol yet nt

[sinkingfeeling]

544. It's called a formulary and every insurance company has them. It is

of the utmost importance that people check the drug formulary for the plan they are about to chose. This is the same thing people who are dependent on a certain drug must go through when they select their Medicare Part D provider. My mother has had to change her providers several times due to changes in her prescribed medicines and one can only do that by looking at the formulary and the tiers of drugs.

Here's an example from Anthem:

https://www.anthem.com/shop/content/olspublic/pdf/2014/english/MAPD_ComForm_Acc_Val_OH.pdf

[questionseverything]

583. yes it is a formulary, that was the point

specialty drugs can not be checked on BEFORE you buy

after you buy you can be denied and appeal and denied and re appeal....all while paying enormous premiums ...lucky us!!!

I remember some guy that said,


I watched my mother fighting cancer, dying and trying figure out insurance company forms from her hospital bed....time she should of been able to spend with her grandchildren and her loved ones

as a nation we embraced that guy and gave him a mandate to change that system but for many we are right back where we started except now no matter how badly insurance acts ,it is by law mandated

[LiberalEsto]

587. We need more consumer protection to protect us from insurance companies

Either that, or single payer.

At the very least, we need to be able to look up their formularies before signing on.

Can the Consumer Financial Protection Bureau do something about this, or is it out of their jurisdiction?

[sinkingfeeling]

602. Then why can anybody go online and get a copy of the specialty drugs?

Here's the one for Anthem BCBS:

https://www.anthem.com/health-insurance/nsecurepdf/pharmacy_NatlAccts_Specialty_DL

[questionseverything]

605. no where in that link does it say what is covered

it says after you have PAID you can ask (beg) the insurance company to let you receive the drug

and they can change it at will according to your link>>>>>

This list may change without notice which may affect your benefit coverage.

[sinkingfeeling]

607. I can't explain it to you. It's how all drug coverage insurance works. Not all drugs

are available under all policies. Special drug lists require special things, like using a tier one drug before being allowed the tier two drug or being pre-approved for the drug by the doctors, or using one brand name instead of another, or having a limit on the amount of the drug you can receive. That's why they're on special drug lists.

Honestly, this stuff has been round since Medicare Part D kicked in. In the case of ACA, the states got to chose how participating companies 'picked' the drugs to be in their formularies.

[questionseverything]

610. people were saying will was wrong for not checking the formulary

before he bought his plan

I posted a formulary to show ,they do not promise to cover certain drugs before you buy...you can only apply after you have paid

your argument seems to be it was always like this and I would agree with that but that does not make it right

[Ms. Toad]

619. The online link for some specialty drugs

is tied to particular plans. The link (and quote) does not say that you cannot find out ahead of time which specialty drugs covered on a particular plan, it says you have to log in to see it online, because what is covered is tied to a specific plan. Have you tried calling, telling customer service person and asking about the plan you are interested in buying, to see whether the drugs you are concerned about are covered?

I have never, on any plan where there was a formulary or a specialty drug list, been denied that information in advance of purchasing the plan. The last time was October. In order to answer my question about a medication in a class that is frequently not covered (and often not listed in formularies), the person on the phone had to find someone on the plan I was considering who was getting that medication to confirm it was covered, and at what price - since it was plan specific. But she found and provided the information to me - as has happened with each of the plans I have had over the last several years.

It is far more effective to find the customer service number and call and ask, than it is to complain on an internet board (which they will never read) that they won't give you the information.

[Ms. Toad]

614. That is not correct.

The last 4 plans I have been on have had a specialty drug category - and in each case I was able to check the coverage and price I would be charged. They cannot, of course, tell me whether an appeal of something which is not part of their formulary or specialty drug list will be approved prior to purchasing the plan - since that is based on unique medical circumstances. But they can (and in my experience always do) tell you the list if you ask.

And, FWIW, I have never lost an appeal (we are billed $60-100,000 a year - so you can imagine I have lots of encounters over insurance issues). In my 30 years of dealing with insurance companies, I have decided not to pursue two claims - out of network co-payment for an air cast which I would have had to drive 100 miles to find in-network, and authorization to see a pediatric (as opposed to adult) orthopedic specialist in connection with a break near a growth plate. Both were related to a doctor I fired for her refusal to assist in the corresponding appeals. I have been successful in obtaining approval for 2 experimental treatments (one surgical, one pharmaceutical), access to numerous step therapy treatments, in network treatment for costly care by an out of network specialist, family coverage for our same gender family (at a 30% reduction in out of pocket expenses) - and many more.

I agree - it should not be so hard, and it has robbed time I could have spent being present for my ill family members. But information, and successful appeals, are possible.

[Control-Z]

644. I was able to make a drug list on the wesite - of any and all level drugs -

and then compare each and every plan's coverage of those drugs before I purchased.

[Hissyspit]

266. "Being a victim is beyond foolish"

Yeah, sure. People just love to get scammed. Read your sentence. It doesn't even make sense.

"Much easier to blame others for your own indifference."

What indifference are you talking about? They've been working on this for months.

And this is JUST like buying a car to tow a boat. (Of course, now that you mention it, car dealers have a long history of being dishonest, unethical scam artists.)

[JEB]

334. Every single insurance company should be regarded

as the heartless lying thieving scum they are. After 45 minutes on hold..."this conversation will be recorded..." FOAD

[Boudica the Lyoness]

446. Could you please tell me what medications I'm going to on

in the future.

Thank you.

[bluestate10]

119. You are dead wrong. There may be alternative medications that work as well.

If a patient insists on a particular medication when other therapies will work that mindset helps NONE of us. I don't know the details of the OP's wife's situation, but I do know that I had three medications that worked for a situation that I had, my plan gave me a choice and I chose it's default, which was the least expensive choice, I am doing perfectly fine with the alternative.

[lapislzi]

262. Excuse me, Dr. Bluestate.

The PATIENT doesn't insist on the medication. Last time I checked, it was the doctors that write the prescriptions, and how fucking DARE a bean counter who wouldn't know how to put a stethoscope in his own ears presume to tell the patient with a life-threatening condition what medication she should be on.

While I am happy for you that you are doing well on the medication that your insurance company chose for you, you have absolutely no business telling others what medications they ought to try.

[uppityperson]

352. "If a patient insists on a particular medication when other therapies will work" and there is the

problem. Insurance companies do not have prescriptive authority in any state I know of, and often other therapies do not work, like in the case of Will's wife.

[Zorra]

94. "Everyone who has ever been deceived by an insurance company is a fool!"

(Post #9 added to the top ten list of things that make DU suck.)

[Egnever]

99. There was no deception

only a failure on Wills part to check their formulary. The insurance company will provide that to anyone that requests it, They have to by law.

[bvar22]

126. Maybe YOU have the knowlege and skills to do all of that,

and if you do, hey great!
..but not everyone is skilled or educated in the ability to see through all of the tricks played on the average American by the Health Insurance creeps.
Do you happen to work for one?
Is that how you know all those words like "formulary".

I only have a Masters Degree,
and have never heard of it before.

YES.
You ARE blaming the victim,
and using this to put on a little arrogant performance about how SMART you are.

It is like Steve Jobs saying
Hey. I built a computer and made a Billion Dollars.
You should do that too,
and if you don't...thats just your own damned fault.


You should be ashamed,
but, somehow, I doubt you can experience that feeling.

<expletive deleted> You!

[bvar22]

258. Yeah, I know.

I should be able to check ALL the fine print in ALL of the policies offered in the Exchange while negotiating through Healthcare.Gov Website... or talking on the phoen with a representative.


How many people who signed up through The Exchange even got a look at their policies?
I think that maybe ZERO could be the right answer.
How do you check the "formulary" over the telephone?
I STILL haven't seen a hard copy of MY policy.

You DO know that in civilized countries,
NOBODY has to do those things?
Yes?

I am not the one calling Will an idiot,
because I signed with an Insurance Company without checking the "formulary" either,
along with several MILLION other Americans.

YOU are the one calling Will and Me and MILLIONS of others idiots.
Well, GOOD for YOU!

This is supposed to be The Affordable Care Act.
and The Exchange was for people who previously were unable to afford Health Insurance.
How many people out of THAT pool of MILLIONS do YOU believe know the meaning of the word "formulary",
much less have the ability to check the Prescriptions, or even pronounce the names of those prescriptions?

YES.
You ARE blaming the victims.
MILLIONS of them.
This particular problem will NOT be limited to Will.

I can't print the words I feel that describe your
Well, everybody should just be as smart as me
smug, elitist, above it all, blame-the-victim attitude.
That is usually reserved for Ultra-(Its your own damned fault)Conservatives and the I Got MINE, FU libertarians".

[JEB]

296. Pretty well sums up my experience as well.

[Enthusiast]

506. A master obfuscater.

[Zorra]

144. Insurance companies have the art of deception down through omission,

evasion, bait and switch, and fine print down to an exact science. Checking the formulary of an insurance company is not always easy, especially after you've been totally beaten down dealing with deliberately insane bureaucracies who eat up most of your spare time when you are just trying to get straight answers from them.

It took me 63 days of intense frustrating, mind numbing struggle in overcoming built in programmatic stupidity to get my insurance plan through the ACA, through no fault of my own, and once I finally got approved for a plan, I was not permitted to examine the overwhelming majority of the details of the plans available to me before I chose one.

Fortunately, I got lucky, and my plan seems to be a good one. However, they apparently deceived my optometrist into believing that they would pay for my thorough eye exam; the optometrist told me the insurance company would pay, and after the exam found out that they were not getting paid. But the optometrist was honorable, and did not require me to pay, and just ate the cost of my exam, because they acknowledged that had told me my insurance was going to cover.

People should not have to go through all this deliberately deceitful, complex maze of crap devised by profit seeking businesspeople whose job it is to rip people off in any way possible in order to receive health services and health insurance benefits.

It sucks, it's evil, and I aim to help destroy the private health insurance industry as quickly as possible by any non-violent means necessary.

[Egnever]

156. Not sure what any of that has to do with checking the formulary before you purchase a plan

Even more so when you have a drug you depend on.

I am not claiming insurance companies are benevolent but the formulary is one thing about them that is black and white. If you dont check it when you are purchasing a plan and there is a drug you need covered you are not a victim.

[TrollBuster9090]

224. As I understand it, no insurance company is required to pay for a medication that hasn't been proven

to be effective. (That's even true in countries with a single payer health care system.) And, if you're talking about a drug that IS proven to be effective, but there are several brand name formulations vs. alternative (generic) equivalents that are proven to be as effective (or in the same ballpark) an insurance provider is free to say you have to use the cheaper one. A problem sometimes arises when somebody is used to a brand name that is five times more expensive than the generic version; or has been using a more expensive formulation that hasn't been proven to be more effective than an alternative, cheaper formulation with the same active ingredients.

That happens all the time; but it's not really a denial of a life-saving medication. It's just a denial of a more expensive version of something that isn't proven to be more effective that some other treatment.

I don't know if that's the case here, though. I'm just saying there's a lot of noise about this kind of thing that goes on whenever people are required to switch plans or providers. And it happened long before the ACA.

[Zorra]

284. I was not permitted access to the formulary before I purchased my plan. nt

[truedelphi]

497. Thank you for relating the realities of the situation.

I am firmly convinced that many of those exonerating or even praising the ACA are younger and healthy and are probably not going to have to actually use the system for quite a while. Or else they re people who are on a premium plan, through an employer or through being able to afford such.

But for people who have to use an insurer that is offering them less than a premium plan, there is a lot of bitter to have to suck on.

Considering the fact that the guy occupying the Oval Office and the Dem majority that had both houses from Jan 2007 to Jan 2011 had continually put out there the possibility of a public option, only to retract such once pressured by industry, it is natural that people are disappointed and if denied coverage like essential meds, even damn angry. There should have been a lot more reform and a lot less in terms of loopholes and give aways to the Big Insurers.

But the Beltway whores are what they are.

[freebrew]

555. You touched on something important..

People w/ certain jobs have 'premium' health plans. The company they work for probably pays a lot of premium for these plans, maybe. If you're getting a subsidy and so getting a 'cheaper' rate, this subsidy is coming from taxes. The insurance company is still getting top dollar for these less than premium policies that should be just as good or better than those so-called premium plans coming from employers.

Anthem can certainly afford to pay for Will's wife's meds. I've been through similar experience and for some reason, the insurance companies would rather be assholes about it. But, from what I've seen, these fights always end up costing the insurance companies more than if they just listened to the Doctor.

[Cha]

180. Yeah, "the insurance company".. maybe pitt should have been "fuck" "fuck" "fuck" "fuck" "fuck"

them.

[Demo_Chris]

118. WTF?!

[bluestate10]

124. The poster made a valid observation. nt

[magical thyme]

318. stating somebody was a fool for not reviewing the formulary before signing up

when YOU ARE REQUIRED TO SIGN UP IN ORDER TO SEE THE FORMULARY

and then it states that your particular plan may not include all the drugs in the formulary

is a lot of things. A valid observation is not one of them.

[Zorra]

316. Third Way Free Marketeers value profit over human well being, so they

don't have a clue as to why the post is so utterly offensive to Democrats and other progressives.

Plus, Pretzel_Winger and his right sock got tombstoned today for engaging in the typical RW behavior of cheating.

[PowerToThePeople]

322. Wow, I did not see that happen.

http://www.democraticunderground.com/?com=profile&uid=298088

Interesting...

[MoonchildCA]

462. There is not enough information posted on the providers' websites to garner this information.

There is limited information on our state site, as well. You can only get the most basic information on what is covered. You can't call--they are overwhelmed and no one answers. My friend signed up for Anthem Blue Cross because she had them before and was familiar with them. She found out, only after she signed up (because you have to be a member to have access), none of her doctors are in her network--doctors who previously took Blue Cross. in fact, the nearest oncologist is 20 miles away, and we do not live in a small town. we have two hospitals here, and neither is in her Network.
She and I both already had "Obamacare." We went from the California Pre-existing Insurance Plan (the absolute best thing ever!), to the Federal pre-existing Insurance Plan (not as great, but adequate), and have now had to transition into the exchange. She has been in pain management for years, and it took her over a month to finally get those meds approved. Her pain management doctor was the only one in her network. He accepted the copay, but now she is being billed for the entire amount--over $200. In-network doctors should only cost the copay. There is no one to call; nobody answers.
She was not sent a booklet on coverage (like our former insurances did). Basically, you're just left out in the cold to navigate it yourself. You really don't know if something is covered until you get a bill.
My husband and I signed up for Blue Shield. We haven't attempted to use it yet, but I'm really stressed after what my friend has been going through.
And full disclosure: I am only alive because of Obamacare. I needed major surgery in 2012; I signed up for CA Pre-existing Insurance Plan, and received a $300,000 dollar surgery the next month. I was prepared to LOVE the exchanges...

[itsrobert]

12. What if my medicine isn't on a plan's formulary?

What if my medicine isn't on a plan's formulary?

If you can't find your medicine on a health plan's drug list in your state's Marketplace, you can request that your plan cover it or give you access to it.

You can request that your insurer cover a medication not on its formulary with the help of your doctor to explain the medical need. If your request is denied, you have the right to appeal your health plan's decision.


http://www.webmd.com/health-insurance/insurance-costs/aca-prescription-drug-costs-faq

[Whisp]

13. I don't think we are getting all the details and facts here...

[itsrobert]

17. Indeed. He's giving up on a new plan because some insurance adjuster advised him not to bother

Why not pursue all angles before the "anger" is posted?

[truedelphi]

385. If the nation's citizenry had been offered real health care reform and not

A Rahm/Liz Fowler extravaganza, no one would have to spend any of their time appealing any thing.

At some point in your happy go lucky life, you might need to use your health insurance. And then you too will get to find out what it is like to have to go without a treatment you need, or a medicine that is essential, due to cost. All the while having to spend hours of your life, that should be being spent productively, dealing with Big Health Insurers.

[theboss]

577. Because he is Will Pitt

He do what he do.

[treestar]

79. I agree, why would an Obamacare plan

leave out a specific medication in a specific case? We are still dealing with insurance adjustors, and people may not like that, but that's what we've got.

And we can't prove single payer plans don't have bureaucratic glitches too.

[Hoyt]

90. They darn sure do. Medicare has no out-of-pocket cap, for example.

And, the drug coverage is subject to even more restricted formularies.

[bluestate10]

130. The accusation does sound somewhat suspicious and was delivered emotionally.

The emotional part pleases some on DU, in particular when the President is targeted, but the emotion doesn't make the claim true. I suspect that there were effective alternatives offered and they were rejected, in such a case even the best plans will reject prescription fills.

[Hekate]

233. Someone's sort of stuck on permanent anger at this point. No, we don't have all the facts.

What we have is a generic "Fuck Obama he's teh evil" post, and I for one have a hard time parsing out what actually happened and what alternatives were tried.

I do know that my husband reads his company-offered insurance plan's fine print every year so there will be no surprises.

We've known what a formulary is for at least 25 years, because some of our meds (especially mine) are routinely denied every single year. My primary doc is sick of countersigning the letter I keep on file in my computer testifying in excruciating detail what side effects are caused by my taking a particular cheap generic, but I print it out and he faxes it from his office with his own note. Every year.

If at first you don't succeed, keep trying. Keep notes in a file, with dates and contact info.

I'm going to get put on ignore for this, or flamed, but the OP married a woman with a severe, chronic, and progressive disease. My sympathies are with them both. But it means he signed up for a lifetime of reading the fine print and doing the research. I wish them both all the best, but Obama is not teh evil because of it.

[SidDithers]

386. Good post...

Sid

[wickerwoman]

477. "he signed up for a lifetime of reading the fine print and doing the research"

Only because he lives in America which, last time I checked, doesn't have a sign up sheet. If he lived in a number of other countries, he and his wife would just go to their doctor and get care.

I have absolutely no idea what a "formulary" is. If I get sick, I don't run to the internets and start shopping for a health insurance plan or researching which medications are covered among dozens of "options". I go to the doctor and get what I need.

But then I live in a country that actually gives a fuck about helping people instead of squeezing every last dime out of them and then blaming them for being broke and sick and tired and too busy to read dozens of pages of fine print specifically designed to screw them over.

What are the hundreds of millions of Americans with below average intelligence or learning disabilities or ESL issues or overwhelming stress from poverty and working three jobs to scrape by supposed to do? Suck it up and believe that they are the problem, not a system that doesn't give a shit about them and is intentionally designed to disadvantage them?

[Hekate]

483. Lucky you. But in the OP's case, he is a highly articulate professional writer, activist, & teacher

...with none of the disabilities you list. He has become progressively more enraged at Obama's perceived perfidy, and it has caused him to blame everything, including his own decisions, on Obama. I've been reading his posts and essays for nearly 12 years, and he's shared a lot about his life on this board. I'm sincere in my sympathy for him and the woman he loves -- but I am not sympathetic to this latest screed, because as far as I can tell he is working backward from a foregone conclusion.

Saying there are "hundreds of millions of Americans" simply unable to cope with the best President Obama and the Dems were able to cobble together given the intense opposition they face is rather overstating the case. If that were so the entire population of the US would be covered by your blanket statement.

I don't know what paradise you live in, but you are not in possession of all the facts about what we are trying to do here, where we live. You are taking the frustrations of some folks on one discussion board -- and in particular one man -- as if they were the whole story, and they are not.

There are a lot of DUers who would like to brainstorm ways to help the OP through this trying time. However, given the progression of his rage at Obama, I am not optimistic of the outcome.

[wickerwoman]

484. I am from America

and I left specifically so I wouldn't have to deal with this kind of shit. I still have family who are going through it and I thank my lucky stars every goddamn day that I don't have to. Emigrating from the US was the single best decision of my entire life.

This is not an issue which is specific to one person and brainstorming ideas to help Will through this one particular crisis misses the point. He's pissed off at a broken system and he has every right to be. Telling him that it's ever so slightly less broken than he is making out (while also suggesting that the burden should be on him to navigate it) is not helping either him or the larger problem.

[truedelphi]

496. I realized about two years ago that being enraged

At a puppet, even a puppet that occupies the Oval Office, was a bit of a waste of time.

[Humanist_Activist]

42. Appealing the decision doesn't guarantee coverage, just a review, and it can still be denied...

for non-medical reasons(i.e. medication is too expensive). By which point the appeals process will eventually be exhausted.

[itsrobert]

51. Yeah, it also can be approved

It doesn't hurt to appeal. Nobody said it has to be approved. I must of missed that part.

[Humanist_Activist]

66. I'm assuming what the OP meant by a 3 month fight is that they already...

went through the appeals process, and were ultimately denied.

After that point, you are SOL unless you can get some type of charity or government help.

[itsrobert]

73. I'm assuming nothing

other that he wants to fuck the President and thinks the President is a used car salesman.

[treestar]

80. The President ends up responsible for all the bad things that happen

But wouldn't get credit for medications approved immediately! Naturally. Nobody like to fight with insurance companies. But then who is to say even single payer would not result in this type of fight? The government might claim a medication not needed where patient and doctor disagree.

[itsrobert]

82. Happens all the time in the Miltiary Tricare System

but there is an appeals process and my wife was able to get the medication her doctor recommended.

[TheKentuckian]

683. They are about a 100 times easier to deal with than say any BCBS

They have the simplest criteria and formulary is easiest get an override on. As far as I can tell, if you have a condition where it is generally agreed that a treatment is effective then it will be covered with little mess at all.

Off label and experimental applications, you may have some trouble but FDA approved comparably simple compared to most.

I suggest Will approach the manufacturer for help, that is often the last line of defense nowadays but you generally will have to be in a situation where they will not cover a formulary alternative for you either.
There are some charitable foundations but funds are very limited because they have been hit up hard for the past few years.

Is this Obama's fault? Of course not.

The problem is of course these maddeningly stressful, quality of life, and even life and death issues were not taken from our plate and this is because mostly we do not have systemic reform but rather what we actually did was really more closely align the individual market with the large group market and improve access via a hodgepodge of approaches in exchange for guaranteed customers and a mainline to the treasury so the deal is over sold.

A lot of people looking for relief will find none, we have the same system as before with some curbs on SOME of the roughest edges. This has turned out to largely be standardization, which is a good thing because the individual market was fucking Thunderdome crazy town but it is still very ugly.

Satisfaction with large group plans is driven by lack of use and employer subsidy, folks that have to use it tend to hate it almost as much as individuals because of the hell they put you through and the costs start to show up beyond premiums and copays.

[Humanist_Activist]

84. I don't blame the President personally, this system predates him by about 40 years...

and the institutional stagnation of it means that the ACA was going to be a compromised compromise that isn't going to solve most of the problems it claims it can solve. Barring an outright revolution, or radical cultural and political shift, we aren't going to see our private/public system fixed completely in probably another generation or two. The ACA may be a good first step, but it isn't the end all, be all of health care reform.

[lumpy]

151. Yes. That's about all I got out of the whine.

[JoeyT]

49. Via HHS.gov

http://www.hhs.gov/healthcare/rights/appeal/appealing-health-plan-decisions.html

Some Important Details

The parts of the Affordable Care Act that concern internal appeals and external reviews apply only to health plans or policies that were created or purchased after March 23, 2010. Plans created on or before March 23, 2010, may be “grandfathered health plans.” The appeals and review rights do not apply to them.

Edited to add: Which is sort of confusing. In one place it says created or purchased, in the other it just says created before may be grandfathered.

[MannyGoldstein]

510. Later today I'm sending the Koch brothers a letter appealing their decision

to not give me $100 million.

How do you think I should spend the money?

[itsrobert]

14. Are prescription drug plans the same in every state?

Are prescription drug plans the same in every state?

No. All health plans in a Marketplace must include prescription drug coverage, but each state sets the list of covered medicines, called the formulary. For instance, one plan may have many more medicines in one category or class than another state does.

http://www.webmd.com/health-insurance/insurance-costs/aca-prescription-drug-costs-faq

[Baitball Blogger]

15. My heart goes out to you and your wife, Will.

There were loopholes with the early HMOs too. We need to work together to get this information out to the executive office. I bet we can make a difference.

[itsrobert]

16. How do I know if a health plan will cover the medicines I take?

How do I know if a health plan will cover the medicines I take?

Check the plan's formulary, also known as a preferred drug list. You should be able to get this from any health plan you're considering. Sometimes a plan's formulary will be on its web site.

The formulary lists each brand and generic name of medicines that the plan will help pay for. To look for your medicines, you need to know:
•The medicine's exact name
•The dose you take
•How many pills your doctor usually prescribes

http://www.webmd.com/health-insurance/insurance-costs/aca-prescription-drug-costs-faq

[bvar22]

50. Thats nice.

What about the medicines I might need next year for a condition I haven't yet developed?

In civilized countries, they don't have to do that.

[progressoid]

18. What? For profit health care screwing people for profit?

Who wudda thunk it.

We also have "coverage". But we don't use it because it's too expensive. We're basically shelling out cash in the hopes we are covered for any catastrophic problem.