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I'm having exactly these problems, with exactly these companies: CVS and BC Anthem. Doctor writes prescriptions; some are limited in doses, some delayed, some w

I'm having exactly these problems, with exactly these companies: CVS and BC Anthem. Doctor writes prescriptions; some are limited in doses, some delayed, some with no copay, some priced barbarically, and some flat out refused. Then the doctor's office has wizards that help advocate and sometimes that works, sometimes there's a delay, and sometimes never. In all cases, the patient suffers. They are already facing a medical condition, maybe serious, plus stress from missing work and home life, stress about the future, stress for paying for it all, and then along comes these sharks who will double it all with more stress and worry and anger. Then on top of that they don't get all the types and amounts of medicine their doctor actually wants, based on science and experience, so they will get inferior treatment in every way. Yes we need to cut the price gouging. Adding friction at this interface is not the way.

Scoundreller 7y ago
> Then on top of that they don't get all the types and amounts of medicine their doctor actually wants, based on science and experience It can also be the insurer saying "Nononono!" to treatments that are unnecessarily expensive. Treatments are often chosen because of marketing, and not because of clinical guidelines. E.g. Blindly trusting a sales rep's "education", or choosing something new out of sheer boredom. It gets dicey when the new treatment is a bit better, but a lot more expensive.
sjg007 7y ago
I am surprised that this hasn't started a class action lawsuit yet. The insurer through delays is causing harm. I'm guessing it's a contract thing though. One thing to do is if your plan is regulated by the state then immediately start an appeal with your state's department of insurance. There are also advocates at some hospitals and insurance companies. The other thing to do is go to a very large academic cancer center... presumably a tier 1 research hospital. Outcomes are also better. They usually have staff that know their way through each insurance company and PBM.
- erentz 7y ago
  Because most people get their insurance through their employer they are usually self funded plans covered by ERISA. Your only recourse is that provided under ERISA which limits damages to the cost you paid for a treatment that wasn’t covered but should’ve been. It’s abhorrent. Congress in making this law 50ish years ago essentially took away people’s right to sue and get justice in this instance. It was a huge gift to insurance companies and it needs to be fixed but people only learn about it when they are exposed to it. I wish there were politicians willing to step up and change this particular law. When people talk about tort reform I think they’re really misunderstanding who such reforms benefit, as in this case it only serves the large companies and allows them to act in bad faith without proper repercussions.
Gibbon1 7y ago
Was talking with my endocrinologist. She said insurance companies are now limiting the amount of insulin she can prescribe. She'll have a patient who's been doing fine with 30 units a month and the insurance company will cut it to 25. And then to 20. My theory is specialists, hospitals, insurance and drug companies are trying to swipe everything that isn't nailed down before it all blows up.
- zaroth 7y ago
  FYI, a 10mL vial of U-100 insulin is 1000 units. I don’t think you can buy less than a 3mL vial (300 units) which is a pen cartridge and I think even those are only sold as 5-packs. I’ve never heard of an insurance company trying to reduce an insulin dose. They definitely pushed back on the number of test strips they would cover (e.g. 5 strips/day vs 7/day) where a prior auth was needed to get coverage at the higher quantity.

Scoundreller 7y ago

> Then on top of that they don't get all the types and amounts of medicine their doctor actually wants, based on science and experience It can also be the insurer saying "Nononono!" to treatments that are unnecessarily expensive. Treatments are often chosen because of marketing, and not because of clinical guidelines. E.g. Blindly trusting a sales rep's "education", or choosing something new out of sheer boredom. It gets dicey when the new treatment is a bit better, but a lot more expensive.

sjg007 7y ago

I am surprised that this hasn't started a class action lawsuit yet. The insurer through delays is causing harm. I'm guessing it's a contract thing though. One thing to do is if your plan is regulated by the state then immediately start an appeal with your state's department of insurance. There are also advocates at some hospitals and insurance companies. The other thing to do is go to a very large academic cancer center... presumably a tier 1 research hospital. Outcomes are also better. They usually have staff that know their way through each insurance company and PBM.

erentz 7y ago
Because most people get their insurance through their employer they are usually self funded plans covered by ERISA. Your only recourse is that provided under ERISA which limits damages to the cost you paid for a treatment that wasn’t covered but should’ve been. It’s abhorrent. Congress in making this law 50ish years ago essentially took away people’s right to sue and get justice in this instance. It was a huge gift to insurance companies and it needs to be fixed but people only learn about it when they are exposed to it. I wish there were politicians willing to step up and change this particular law. When people talk about tort reform I think they’re really misunderstanding who such reforms benefit, as in this case it only serves the large companies and allows them to act in bad faith without proper repercussions.

Gibbon1 7y ago

Was talking with my endocrinologist. She said insurance companies are now limiting the amount of insulin she can prescribe. She'll have a patient who's been doing fine with 30 units a month and the insurance company will cut it to 25. And then to 20. My theory is specialists, hospitals, insurance and drug companies are trying to swipe everything that isn't nailed down before it all blows up.

zaroth 7y ago
FYI, a 10mL vial of U-100 insulin is 1000 units. I don’t think you can buy less than a 3mL vial (300 units) which is a pen cartridge and I think even those are only sold as 5-packs. I’ve never heard of an insurance company trying to reduce an insulin dose. They definitely pushed back on the number of test strips they would cover (e.g. 5 strips/day vs 7/day) where a prior auth was needed to get coverage at the higher quantity.