I have talked about this before (https://livingwithfh.blogspot.com/2017/04/a-helpful-health-insurance-alas-there.html), and as anyone taking Praluent or Repatha knows: ordering a new prescription or even a refill can be a pain in the rear-end. You always get denied by the insurance, always turned around, even when you know your reasoning for asking for these drugs is legitimate. They don't seem to care. It's not the first time when you realize that health insurance companies are not in the business of saving lives, but in that of making money. Pretty much a platitude, right?!
So,
when it was time for me this month to renew my Praluent (this would
have been my third renewal), I started an online journal. I wrote
down the name of every person I talked to at the insurance company,
at the specialty pharmacy, at my doctor's office and I was prepared
to document every step of the way so I can show someone, anyone,
where the process seemed to have been broken, should I be denied.
I
took very detailed notes. I talked to the insurance first. They told
me they cannot, by law, call my doctor; that they make up the list of
questions / reasons for which I should be on Praluent, and that I
have to call my doctor myself and have them write up this note with
all the reasons that are approved by the insurance of why I should be
on it. Then, the doctor has to fax this note to the insurance
company. Then, the doctor has to also call the specialty pharmacy.
When the pharmacy gets the call from the doctor that I was prescribed
this drug, they cannot fill it unless the insurance approves that
prescription. So, the pharmacy would call the insurance and the
insurance would have had the questionnaire filled out from the
doctor's office and would give them the OK (based on what the doctor
answered) to fill the prescription. Or … they would deny refilling
it.
If
your head hurts, it should. The process is a spiderweb of convoluted
bureaucratic loose ends and it is not designed for ease of access.
This
year, I am also in a new state, and have a new cardiologist who is
not the cardiologist that originally prescribed Praluent to me, two
years ago. So, I was doubly nervous: I had to renew my prescription
(so, renew, after originally having been approved) twice before and I
was denied several times before during the renewal process. I knew
this time would not be any different. Plus, not really being familiar
with the staff of my new cardiologist, I was even more nervous that I
would get denied so many times, an appeal would not even be possible
anymore.
But
sometimes, by the grace of Karma, or God, who knows?!, our worst
fears are not met. I went to my new doctor and explained the maze to
him. He smiled and told me to not worry about it, that the process
has become easier over the years and a renewal is much easier than
ordering a new prescription. I was dubious. I gave him the list of
questions that the insurance needed answers for with the fax number
for my insurance. Then, I gave him the phone number of the specialty
pharmacy saying that I needed him to order the drug from the
pharmacy. I was so scared he might get the two numbers confused: the
insurance needed the questions answered and the pharmacy needed the
prescription. And I talked to the doctor, but I know he is not the
one actually doing all this, that his assistant or nurse might do
this and between me telling him and him telling her what is needed
something might get lost.
When
it was time for my normal refill, I called the pharmacy to see if
they had received a call from the doctor yet and could they please
call the insurance for the OK. When I called them they said they did
receive the call from the doctor and they also received the OK from
the insurance and if I wanted, they could send me the new refill in a
couple of days. I asked them, still dubious, how many refills I had
with the newly renewed prescription, and they said 11 – that the
new prescription is valid for the whole new year. I was in awe! This
had to be the easiest Praluent refill in the history of Praluent.
To
the time I write this, I am still not sure what changed: either my
new doctor has had more experience with ordering these drugs than my
previous one and he did tick all the possible boxes requested, or the
health insurance/ specialty pharmacy business has gotten a little bit
less rigid?
Not
sure.
The
couple of things I made sure that my new doctor had were:
- the results of my genetic test that shows I have HoFH
- the total Cholesterol and LDL Cholesterol numbers from before I started Praluent and the levels I am at now
- my history of CAD and heart surgery.
Hopefully
that's all they needed and what he sent in.
Like
I said: not sure what worked, but I am grateful it went well.
Now,
the next big bump is renewing my benefits later this year: I am
hoping that my employer will continue using the same insurance as we
have now. Changing insurance companies at the end of this year would
mean starting this process over with another company – and that, I
know, and my doctor agreed, is much harder. Hoping for consistency
going forward!
Good
luck to all who are going through this process! These drugs have been
a real live saver for me!
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