Ms. "X" came to see me a few days ago. She is a pleasant middle-aged woman with multiple medical problems, most of which could be cured or curbed by losing weight--hypertension, hyperlipidemia, "pre"diabetes, esophageal reflux and asthma. She belongs in the "super" obese category and her financial and familial problems are not helping her motivation to lose weight. She used a medication called buproprion in the past for her depression and it was helpful. It does not promote weight gain like so many other anti-depressants, so I prescribed it, hoping it would help normalize her mood. When she went to the pharmacy she was told that her doctor needed to get a "prior authorization" on the drug. For those of you who don't understand this terminology, it means my office must call the insurance company and justify why she needs this medication rather than another. Buproprion is the only medication in its class and is generic. I was surprised that this was a problem. Despite being a generic medication, it IS still expensive--$130 for a 30 day supply. However, because it is the only medication in it's class I've never had a problem with insurance coverage. Nonetheless, we called and were told that Ms. "X" plan doesn't cover buproprion, we would have to write a letter of appeal and send it to Arizona. (I work in Kentucky). There was no fax number to send it to, just snail mail. We sent it certified but I still want to know why United Healthcare was not covering this medication since I have plenty of other patients with this insurance.
Here is where the saga begins. My medical assistant called the drug "vendor" who dispenses the medications. After speaking to three people whose native language is NOT English, she turned it over to me. I got through to someone in this country who referred me to someone else. Finally that individual told me that this was not a "United Healthcare" problem, it was due to her own company's policy. She needed to call her HR department to find out what the problem was. I persisted and was told I needed to call United Healthcare, not the drug vendor as they just did what United Healthcare told them to do. So I tried that route. I spoke to two individuals in another country and was finally routed to someone a little closer to home who apologized and told me to call my regional provider rep. By this time it was 5:30 pm on a Friday afternoon. Temporarily defeated, I resolved to begin again on Monday. On Monday I began my dialogue with him. At no point have I had access to a medical director in the company. That would be a peer-to-peer discussion and apparently the medical directors at United Healthcare don't consider me a peer. I can't decide if that's a good thing or a bad thing. Anywho...after several back and forth discussions it appears that the company that my patient works for is "self-funded" and the company has decided not to cover buproprion. So I said to the United Healthcare rep--OK, fine. But SOMEONE made a MEDICAL decision regarding not covering this medication. If United Healthcare is responsible for administering the plan, they should also be responsible for seeing that medical decisions regarding coverage are consistent with good medical care. For the umpteenth time--WHO IS RESPONSIBLE FOR THIS DECISION AND HOW DO I TALK TO THEM?????? We are now ten days out from when I wrote the prescription and still, no answer.
I have encouraged the patient to contact the Attorney General's office and register a complaint with the state Insurance Commission because, guess what? I CAN'T DO IT! Only a patient can.
Believe me, I rarely get mad enough to devote this much time to insurance coverage issues. And there are plenty of doctors, much smarter than I am, who would never, ever get involved in these sorts of issues. But every month the problems with coverage seems to multiply--medications, lab tests, radiologic tests, other diagnostic tests, hospital admissions, durable medical equipment. My life is awash with pre-certification, medical record audits, pre-authorizations and appeals. This blog has not yet covered the number of insurance company documents I get tell me what tests I'm NOT getting on patients that I should, what medicines I'm NOT using in patients that I should...another blog for another day. And people wonder why doctors are so frustrated!