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Momo Fali's: Red Tape

Wednesday, February 18, 2009

Red Tape

It has been a stressful week here at the Casa de Fali. My husband has been working 16 hour days, and both of us are playing a large part in the organization and execution of a charity event which stretches through this upcoming weekend. On top of that our kids are being shipped off, to two different locations on Friday and Saturday too. That alone takes a whole lot of planning. If they aren't on my list, I'll likely forget to pack one of them.

But the reason I am exceptionally on edge right now is because of a nightmare of epic proportions. A bad dream full of red-tape, labeled with words like "effective dates", "claim forms", and "benefits". And let me tell you, they don't put that little skull and crossbones on Rx bottles for nothing.

Now I am not one to complain too much about health insurance. I had two premature babies, and have a son who has had nine surgeries and lots of hospitalizations. My daughter's bill from her stint in the NICU was $135,000. Not one to be son's combination of services has put him well over that figure.

We will never put into health insurance what we have taken out.

That may not give me any right to complain, but it also puts me in a position where I know a lot of the ins and outs of the industry. And it is one messed up industry.

February has put our family in a sort of insurance limbo, and we are not a group of people who can afford to be in that situation. We have been somewhere between COBRA benefits through my husband's former employer and having an exception made to our effective date with his new one.

While all this has been up in the air we have continued to need prescriptions. My son desperately needs his reflux medication, he and I both take something for asthma, and my daughter came down with strep throat. In the past two weeks, we have paid our pharmacy nearly $700.00, fully expecting to be reimbursed.

We were, in the sense that yesterday nearly half of that was applied to the deductible on our new plan. But the reflux medicine my son desperately needs? The one that he has to have in order to not throw up every day? The one that costs $388.00 a month? It's not covered at all.

Not only are we out that money, but now we get to go playing around with G.I. medications until we find something that works comparably well. The cocktail he's on now took over a year, and a LOT of screaming (by both of us) to come up with...and now we throw that recipe right out the window and start over.

That is why our system is flawed. This kid is six years old and doesn't deserve to be in pain, or vomit every day when there is something out there that will stop it from happening. His parents shouldn't have to go bankrupt to provide it for him either.

So if you don't know where to find me, just look for the mom banging her head against the wall. Though I won't bang it hard enough that I'll need to use my health insurance. You can be sure of that.

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Big hugs! We are on independent health care (aka very pricey but covers next to nothing unless you fight).
I would call the insurance company and appeal. Make sure your son's dr. also sends them a letter claiming it medically necessary. And that if they don't cover, they should tell you what they do cover and make sure it works as well as the current med.

Right now we are battling an MRI my son had--it came back normal so insurance does not want to pay because mental health is not covered and his learning disability was labeled mental AFTER the MRI because the MRI came back normal--does that make sense?!
What a nightmare. Fighting insurance companies is the worst. Is there anything your doc can help with? I hope things change for the better soon.
Oh Mo ... it's worse than I thought. That is horrible to have to deal with that. If it isn't one thing, it's the insurance company. Grrrrrr.
MoMo: I heard that banging, now I know what it is. I'm sorry it is that way, I know whereof you speak.

Yarg. You hit it right on its ugly head. Wishing you some resolution soon.
Um no - you have every right to complain. It's not right, and your son shouldn't suffer for that. I don't blame you one bit.
This might be a very dumb question, and you have every right to roll your eyes, but have you gone to the pharmaceutical company directly? Seems to me there has to be a compassionate soul out there in that biz somewhere who can provide some help. Anyway... we're praying for you all.
This country is so effed up on so much. This is just one of the many problems, but to me? It's one of the most important. And I don't even have a sick kid.
That's just ridiculous. How on earth..?

I'm so sorry. I have nothing but platitudes and hugs.
So I"ll give you the hugs and save both of us the words.
Oh I'm so sorry. There's nothing more frustrating than dealing with insurance nightmares. And trust me, I know as I'm approaching the 3 year anniversary of my car accident. Five surgeries, 3 years of PT ... and our insurance covers SIXTY DAYS of PT. Can you hear me screaming?? Sending huge hugs your way!
I would also suggest checking into the company directly. If that doesn't work, and your doctor can't get it pushed through, never assume the pharmacy you are currently using is the cheapest.
Sometimes you just gotta fight to prove a point. You've got nothing to lose by making the life of every every service rep on up to management at the insurance company as miserable as they are making you. Keep on!
I have tons of room in my basement for the hubs and kids, and you can sleep in my bed. Just sayin'. Canada rocks.

Also, medicaid? Can you get interim relief? Also, when I was in insurance hell, my ped got his vendors to give me loads of free samples, getting me through a really hard patch.

Thinking of you, babycakes.
Yikes! I hate all things health insurance related. We've danced the little COBRA jig lately. Sadly, the COBRA was better than my husband's new employers insurance. We're finding a number of things left uncovered as well. Not cool.

My little guy has reflux, too. I know how miserable it can be. Sending lots of positive energy your way. Hope you are able to strong arm them, or find a new med as quickly and painless as possible.
Like Mr. Lady, we got samples when we needed them. This so completely sucks. I don't know what I'd do if our little girl's seizure meds weren't covered. We went through all that searching for a new medicine while your child slowly disappears stuff. If you have to go the new med route, I just hope it's really quick.
Oh man, I am so sorry! You are right - the insurance system is completely flawed. I really hope you can get something working for your family soon.
Grrrr, am not going to get started on THIS topic, other than to say it completely bites.
I'm so sorry this is happening to your family. I hope that your son is able to find a new reflux medication quickly - how terrible that the old meds aren't covered. :(
As you say it doesn't seem right, the solution is right there but the red taps says no.

I hope you find a swift alternative.
*hugs* I hope you guys can find another cocktail that works soon! Praying for you...
'Member that year that the CDC claimed a shortness of the flu vaccine? OUr ped refused my kids the vaccine claiming they were 'healthy kids' and could be skipped. So dontcha know when one of the kids came down with the flu, and I was at the pharmacy to fill a drug that was 200 bones I went all kinds of batshit crazy. And now, I am all hot and panicked for you.
My son and I don't even have insurance....I can't imagine what would happen if we were in your position....

I agree that you should try for some samples and don't stop bitching at whoever will listen...somethings got to give.
Our health care system is a mess. Your family is living proof of that! Hang in there!
I hear ya, sister! That is completely wrong!

My husband's combined meds run us over $1,000 and that is WITH insurance!!!! NUTSO!!! And his employer just cancelled all family insurance! The kids and I will be without insurance on Mar. 1...UGH!!!!! Got any room on that wall for a fellow head banger???
so that is what that sound was....!

Man, that completely sucks. I really believe that until we take money out of the equation (namely, for profit insurance companies), we will continue to struggle with this and it's the innocent people like your son that get hurt.
Oh Momo, that completely sucks. I've been there. Is there any chance that your GI doc could call the insurance and say your son failed the other drugs and this cocktail is needed?

Try not to bang your head to hard...from experience, I know it hurts! :)
As someone with a $9000 co-pay on my hospital bill for January and February and with one last MRI to go, I so much hear you. People who worry that the government will limit our healthcare, well, insurance already does, and does it badly. I'm so sorry!
I've been dealing with some insurance issues to with some of my families at the Children's Hospital and so I can somewhat relate. I hope you enjoy your charity fundraiser and I will be crossing my fingers you all find a solution to my favorite kid's stomach medicine :]
I am thankful for the coverage that we do have but angry that we are STILL fighting bills from 2006 when our son was in NICU (and subsequently passed away). Due to coding and clerical errors we have been in limbo with charges to us totaling over 900k. Yes, nine hundred thousand dollars. UGH.

Moving on though, check out this site under 'digestives' and see if you can find any relief for your son's meds cost until insurance sorts itself out. They have asthma meds, too. Yes it's an overseas pharmacy but I have used them for years and the products are safe (and so, so much cheaper).

(And no, I'm not shilling for them or spamming, I promise. They have just been a blessing to us with our/my med costs over the years).

I hope your kids grow out of their ailments. I'm sure it's hard on their little bodies, as it is on your nerves (not to mention the checkbook).

Are there any humanitarian programs in your area whose generosity might be of some relief and benefit?
The system is so incredible messed up and it's people like you and your kids who get stuck in the hell. I'm so sorry. I wish it could all be better with the click of my mouse.

But it can't, so just pretend I'm rubbin up on you for happy feelings.
i just got some meds for my daughter yesterday. just an antibiotic, but it was $120. thankfully we do have insurance and only had to pay $20 of that. it did scare me though. our job is on a timeline that is quickly approaching the end. i can't imagine having to pay the full price for stuff!
I am feeling for ya here. Insurance companies cause the biggest amount of hassle for people...especially doctors. People are wringing their hands all over the place and it sucks badly. I hear of some people that have to pay $2 to 3,000 a month for their Rxs, especially if they are taking multiple ones or cancer meds...chemos, injections and specialty meds are a fortune. They take a long time to get approved on most formularies. I guess at the end of the day we all have to do our part but it does stink. Hopefully you get a better solution soon.
BTW, I have an award for you.
As a Canadian, I can't even comprehend those medical bills. I'm not going to tell you it's all sunshine and butterflies, because it's not, but still.
A second thought that should have come to me sooner: contact the manufacturer of the med. Almost all of them have programs to help out people who need their med but are up a tree financially. I have a cousin on the $2k/month med, the one that didn't work for me but it does for him, and he gets it for $500 a month, quarter price, from the manufacturer.
Wait, sorry, $2k a dose, not a month, and it's every other week.
Poor little do you even BEGIN to explain something like that to a six year old?
that's absolutely horrible. I hope it all gets resolved and soon.
I hear you barking Momo!

When I was laid off from my job while pregnant, luckily my husband had his own employer-paid (for him) coverage (between NICU and heart surgery he's probably around $500K or so). We put our son and his massive medical bills onto that until we learned WAY after the fact that they cancelled without notifying us.

Gotta love that Genetic Testing bill from the lab that needs to be paid out of pocket. Like it wasn't hell trying to find a vein over the course of 2 days on this kid to get 2 vials of blood....

Then I had to try to find a good insurance policy that took pre-existing conditions (I know, I know-you better stop laughing at that misnomer). We found something that resembled a steaming pile of poo that cost us fairly little each month, and covered even less so we're now indebted to various doctors and hospitals. Unfortunately (way after the fact) I learned from a friend in the medical field that you can contact various providers (hospitals, doctors, even pharma companies) and ask for discounted if not even free care/products. You might want to contact the maker of the reflux meds and they might have a plan that provides it at a lower cost or free.

It's worth a shot calling rather than pretending you're House and testing various meds out.

Good luck.

I hate insurance.
The US health system is all about making money and screwing over people as far as I can tell.

I'm sorry you and your family are going through all of this. It sucks.
insurance issues are the PITS.

health insurance was one of the big reasons i delayed quitting my job for so long.

and now that i'm working for a new company, i have to figure out how to transfer meds from an hmo to a ppo without having to start over with evals.


i feel your pain, and i think it sucks major for your boy.
I have come to hate the very words "health insurance" while at the same time wishing with all my might to be covered by it. Our system is completely screwed up.

Can your ped appeal to the ins co. pointing out this is the only combo that works for your son?

Also, and this may not even apply, but I think there is an Ohio program that lets kids who have special health concerns buy into the Medicaid program in the state, even if you make 300% of the poverty level. I'm not sure if your son's medical problems are serious enough to qualify, and you may have already looked into it, but I wanted to throw it out there.
I hate those formularies. My meds just got put on it last year and there's over 30 million people on it!!
I will be praying for you, FIGHT IT!
Insurance is CRAZY like that. Since I lost my job and cannot afford COBRA, Ive been paying out of pocket for all of my scripts. And its killing me.
That's ridiculous. There has to be SOMETHING that they can do. Ugh, Momo, I hope this all gets worked out soon. :/
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