Good Thoughts

peteandpete said:
Thought I would share the latest example of the magic of American health care. I am a retired teacher and every few years they retirement system elicits bids for their coverage apparently. We received notification about this change over late last year, that CVS Caremark would replace the previous provider, Express Scripts. I contacted my local pharmacy, my specialty pharmacy, and the state retirement folks (PEBA) for assurance that everything would be okay. I received a letter from CVS Caremark (Aetna) that my GENERIC cancer medication (abiraterone) would not be covered. As one can imagine, this was terrifying news. Fortunately, I was able to get through on the phone to a representative. She shared information that, of course, was not included in the letter: there were two medicinal alternatives, including the name brand of abiraterone, zytiga, which is normally more expensive; there is a three month grace coverage period; and the doctor can ask for an exception. I took the opportunity to ask the representative if everything else would be covered and she said that she thought so; however, representatives couldn't access that information for certain. They would only know when clients received letters and called in to confirm. This is the kind of thing that no one dealing with a serious illness should have to experience.
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I'm sorry you are dealing with this - sounds horrible. And to think that you are clearly more intelligent and on top of things than many patients - there are many who are less able to advocate for themselves who are severely impacted by situations like this.

Our health care system is a disaster. And all anyone wants to do is just blow it up for political reasons rather than come up with improvements. Three of the four members of my family receive drugs from specialty pharmacies and managing it is a nightmare. We finally are in a somewhat good place but still have issues. We considered switching from my wife's health insurance to mine to save a bit of money but my insurer made it so difficult that we just stuck with what we knew for fear of any potential gaps. And our poor doctors spend more of their day managing medication relationships with insurers than actually practicing medicine.

Good luck!
 
CrazyNotCrazie said:
I'm sorry you are dealing with this - sounds horrible. And to think that you are clearly more intelligent and on top of things than many patients - there are many who are less able to advocate for themselves who are severely impacted by situations like this.

Our health care system is a disaster. And all anyone wants to do is just blow it up for political reasons rather than come up with improvements. Three of the four members of my family receive drugs from specialty pharmacies and managing it is a nightmare. We finally are in a somewhat good place but still have issues. We considered switching from my wife's health insurance to mine to save a bit of money but my insurer made it so difficult that we just stuck with what we knew for fear of any potential gaps. And our poor doctors spend more of their day managing medication relationships with insurers than actually practicing medicine.

Good luck!
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You are correct in your assessment. Sending good thoughts to you in your efforts to deal with these challenges. Thanks for your response.
 
peteandpete said:
Thought I would share the latest example of the magic of American health care. I am a retired teacher and every few years they retirement system elicits bids for their coverage apparently. We received notification about this change over late last year, that CVS Caremark would replace the previous provider, Express Scripts. I contacted my local pharmacy, my specialty pharmacy, and the state retirement folks (PEBA) for assurance that everything would be okay. I received a letter from CVS Caremark (Aetna) that my GENERIC cancer medication (abiraterone) would not be covered. As one can imagine, this was terrifying news. Fortunately, I was able to get through on the phone to a representative. She shared information that, of course, was not included in the letter: there were two medicinal alternatives, including the name brand of abiraterone, zytiga, which is normally more expensive; there is a three month grace coverage period; and the doctor can ask for an exception. I took the opportunity to ask the representative if everything else would be covered and she said that she thought so; however, representatives couldn't access that information for certain. They would only know when clients received letters and called in to confirm. This is the kind of thing that no one dealing with a serious illness should have to experience.
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I too have caremark now from peba .
I get switched again in march to silver scripts or something. Plus a medicare supplement.
Family stays on the standard plan .
My daughter works in the industry. Im leaning on her heavily.
Its confusing. I have to check on dental ect.
Getting information is like getting blood from a rock.
Peba had my calculations wrong and had to back pay me thousands . Doing the legwork through chemo is glorious.
Keep the faith amigo.
 
wavedukefan70s said:
I too have caremark now from peba .
I get switched again in march to silver scripts or something. Plus a medicare supplement.
Family stays on the standard plan .
My daughter works in the industry. Im leaning on her heavily.
Its confusing. I have to check on dental ect.
Getting information is like getting blood from a rock.
Peba had my calculations wrong and had to back pay me thousands . Doing the legwork through chemo is glorious.
Keep the faith amigo.
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You too my brother. Stay strong!
 
peteandpete said:
Blood work good. PSA remains low. Doctor says it's okay to use the name brand instead of the generic version. Wearing my Sun Bowl t-shirt today and will wear one of my ACC Championship shirts to oncology on Thursday. The post flu cough has finally gone away. Thanks for the support everyone.
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Glad to hear it. Thought I had a blockage went to hospital Sunday. Flu was rampant i found a corner and hid. Cts showed nothing .must have eaten something that caused a mimicked reaction. I've been tightening up and changing my diet as my gluclose is high. Eliminating as much sugar and things I can.
On a side note my liver is holding steady according to the CT. Mri on my 55th birthday next week. My kids and wife are eating better because of my liver issues( scared straight scenario). So im counting that as a positive. Its made them health conscious.
Here's to a better health year for us all.
 
CrazyNotCrazie said:
I'm sorry you are dealing with this - sounds horrible. And to think that you are clearly more intelligent and on top of things than many patients - there are many who are less able to advocate for themselves who are severely impacted by situations like this.

Our health care system is a disaster. And all anyone wants to do is just blow it up for political reasons rather than come up with improvements. Three of the four members of my family receive drugs from specialty pharmacies and managing it is a nightmare. We finally are in a somewhat good place but still have issues. We considered switching from my wife's health insurance to mine to save a bit of money but my insurer made it so difficult that we just stuck with what we knew for fear of any potential gaps. And our poor doctors spend more of their day managing medication relationships with insurers than actually practicing medicine.

Good luck!
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Allow me share a sentence that really helped me when I was dealing with insurance companies willful delaying tactics and general incompetence/intransigence. Its this: "I'm starting to think I need to hire an attorney". It was impressive how quickly things got sorted after that.
 
howardlander said:
Allow me share a sentence that really helped me when I was dealing with insurance companies willful delaying tactics and general incompetence/intransigence. Its this: "I'm starting to think I need to hire an attorney". It was impressive how quickly things got sorted after that.
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My late mother was a lawyer - primarily did real estate work and never set foot in a courtroom. I believe she would say "I'm going to Esquire them" - she thought most lawyers who put Esq. after their names were incompetent hacks, but if she needed to scare someone, she would use letterhead that made it clear she was a lawyer or would call and say "Hi, This is CNC's Mom, esquire, and I'd like to discuss this matter with you."

I think saying you are a doctor can also be somewhat effective in these types of situations, and I have known academic PhD's to put that to good use - the insurers don't need to know you are a doctor of French literature...
 
CrazyNotCrazie said:
My late mother was a lawyer - primarily did real estate work and never set foot in a courtroom. I believe she would say "I'm going to Esquire them" - she thought most lawyers who put Esq. after their names were incompetent hacks, but if she needed to scare someone, she would use letterhead that made it clear she was a lawyer or would call and say "Hi, This is CNC's Mom, esquire, and I'd like to discuss this matter with you."

I think saying you are a doctor can also be somewhat effective in these types of situations, and I have known academic PhD's to put that to good use - the insurers don't need to know you are a doctor of French literature...
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It is sad, but when I have had insurance coverage problems I “letterheaded” them — sent them an email or correspondence that quiet-flex let them know I’m a lawyer. Throw in a comment that I wanted information on “similarly-situated individuals” who had the same issue in the last four years.

It is really sad that this is sometimes necessary to get them to do right. And it shouldn’t even be a flex. But it has worked for me many times over the years.
 
OldPhiKap said:
It is sad, but when I have had insurance coverage problems I “letterheaded” them — sent them an email or correspondence that quiet-flex let them know I’m a lawyer. Throw in a comment that I wanted information on “similarly-situated individuals” who had the same issue in the last four years.

It is really sad that this is sometimes necessary to get them to do right. And it shouldn’t even be a flex. But it has worked for me many times over the years.
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Years ago, I was Branch President of a financial company, and my customers were able to have accident insurance on their accounts. Once in a while the insurance company would deny paying a claim for a customer. So, I would write a letter to the insurance company telling them that my customer was going to contact the insurance commissioner for help. 9 times out of 10 the claim was then be paid. What's the old saying, a squeaky wheel gets the grease?
 
OldPhiKap said:
It is sad, but when I have had insurance coverage problems I “letterheaded” them — sent them an email or correspondence that quiet-flex let them know I’m a lawyer. Throw in a comment that I wanted information on “similarly-situated individuals” who had the same issue in the last four years.

It is really sad that this is sometimes necessary to get them to do right. And it shouldn’t even be a flex. But it has worked for me many times over the years.
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What gets you more respect - telling them you are a lawyer or that you are a DBR Mod?
 
jv001 said:
Years ago, I was Branch President of a financial company, and my customers were able to have accident insurance on their accounts. Once in a while the insurance company would deny paying a claim for a customer. So, I would write a letter to the insurance company telling them that my customer was going to contact the insurance commissioner for help. 9 times out of 10 the claim was then be paid. What's the old saying, a squeaky wheel gets the grease?
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ya, it's pretty sad...many insurance companies automatically deny claims, they know X % of people won't appeal or do anything.
I've had great success myself with the Vermont Banking and Insurance department, one crisp letter from them gets attention.
 
budwom said:
ya, it's pretty sad...many insurance companies automatically deny claims, they know X % of people won't appeal or do anything.
I've had great success myself with the Vermont Banking and Insurance department, one crisp letter from them gets attention.
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We (by we i mean my wife)had a 6 month battle over prescription infant formula.
 
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