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[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.