A question about Angelina Jolie and Double Mastectomies

[Ms. Toad]

13. Yes, but...

most of the "insurance wouldn't cover" is a matter of incompetence (not that it should matter).

Case in point (although less major):

My spouse has off the scale allergies, and most of the nasal sprays destroy the lining of her nose leaving her the choice between debilitating sinus headaches and a constantly bleeding nose. (The sprays are on top of at least three other daily allergy medications and desensitization shots which still can't keep the symptoms at bay.)

The doctor gave her a sample of a dry spray which didn't irritate the lining of her nose and kept the sinus headaches at bay. He told her that her insurance probably wouldn't cover it and that the way to start was to try to fill a prescription, have it denied, and appeal it.

I looked up the policy and found it is a step therapy, which means she has to try a drug on the regular formulary first (she's tried 3), and that it is a simple matter of calling the insurance company, initiating a pre-approval process (which can be completed instantly by phone) and getting approval. I gave that information to my spouse which (because of other health issues) she didn't get to him.

His office tried repeatedly to submit prescriptions. They kept getting rejected and finally just ordered a very costly substitute that she can't use(and insisted that they had gone through the appeal process and had been denied the appeal - which I know can't happen without generating notice to us of our appeal rights. I blew a fuse. Got on multiple phone calls (compounded because no one will talk with me because of HIPPA and my spouse (for the same health reasons) can't handle the negotiations. Once I got the insurance company to initiate the pre-authorization (after verifying there were no appeals filed - just repeated resubmission of the same rejected prescription), the process took less than an hour.

We had a similar experience on a different medication for my daughter. It required an intermediate test to determine what kind of fungus she had. She had an advanced test - which established not only the kind of fungus, but which anti-fungal medications it was sensitive to. Because it wasn't the exact test it was initially rejected. When we were able to link the doctor and the insurance company together it was approved instantly.

Any doctor with a contract with a particular insurance company should know how to obtain approval for a step drug, or an out of formulary drug which is required to treat a particular bacteria or fungus. Far too many don't. (And the brick wall, in my experience, can come from either the provider or the insurance company - but it is knowing my plan and pushing until one or the other gets tired enough of being beat up on that tears it down. And, with the most insurance savvy docs, the wall doesn't exist - I have been approved for at least two out of formulary medications or procedures which were infamous enough to be the subject of medical dramas because of this kind of nonsense. I was permitted to use them because the physicians who took the initiative to convince the insurance company that (in one instance) $600 of outpatient medication was a lot more cost effective than at least 2 weeks hospitalization. People now would laugh at the idea of hospitalization rather than medication, but it was nearly unheard of at the time.

But "should" and reality don't always match. I would not be surprised if the refusal above was because the doctors weren't familiar enough with the insurance plan - and the patient/family didn't have the resources (experience, time, specialized knowledge, money) to be able to push the right buttons.

It stinks. And no one, when they are at their most vulnerable, should have to fight the insurance companies. And certainly no one ought to be dying because the medication needed to keep them alive costs $6000.