Monday, November 11, 2013

Since Health Insurance has been a topic of conversation lately; let me tell you a story...

There has been a lot of talk about ACA/Obamacare and problems getting and keeping insurance ... It has me worried that this is just the calm before the storm.  Although we haven't had our enrollment yet, my employer has told me not to worry.  And I shouldn't have to - we get our health care through my employer which is a group of over 200 employees, and with that I pay through the nose for a decent HMO.  Usually, I love my HMO, however, recently we experienced our first problem that put Jenelle in a life threatening situation.

Insurance policies are changing everyday, and it seems we keep paying more out of pocket.  With an HMO, more hoops are added to jump through; especially when drugs that were once approved now need special "authorization."  Our problem started last month when I tried to re-fill Jenelle's Vimpat.  NOTE - Vimpat is not a newly prescribed drug for Jenelle, but rather a drug that she has been taking successfully for nearly 4 years.  When I went to Target on October 15 to get her monthly supply... by the way, I LOVE my Target Pharmacy (located at Irvine North on Jamboree in Irvine) for reasons that will reveal themselves as this goes on... I was informed that our insurance, Aetna, did not "approve" the refill.

At first, it didn't really phase me.  "Oh, I must be a week early" I thought.   I usually make a trip to Target Pharmacy, which is now 5 miles out of my way since our move, at least every two weeks to pick up Jenelle's medications.  I know their staff very well, and we are usually on a first name basis.  I left that day with the other prescriptions that were ready and didn't think anything of it.  When I got home, I realized we were down to 4 pills of Vimpat.  I was not early and something was wrong with the authorization. 

I went to Target the next day, and they tried to run it again.  Again, it was denied - this time, it said they were waiting for "authorization" paperwork from Dr. Shields at UCLA.  So, give that I had two days left, Target gave me 6 pills to carry us over a few days until the insurance glitch worked itself out.  Some pharmacies would demand I pay the full price and then reimburse me later.  My Target doesn't do that to me if only for the way that they truly care for Jenelle.  By the way, my Target (Irvine North on Jamboree) has two fantastic employees who really understand the ways of the insurance billing world.  Anna and Stephen.  Go there, ask for them and thank them for all they do for Jenelle.  So with a 3 day supply in hand, Anna and I agreed that she would call the doctor and work on it.  I thought nothing of it until I got the mail that weekend.

That weekend I received a 6 page letter from Aetna explaining that they were denying coverage of Jenelle's Vimpat... a drug that she has already been taking for nearly 4 years ... because,

"Coverage of the requested drug can only be authorized if:

  • The member has a diagnosis of partial-onset seizures.
  • The member has documented concurrent therapy with one of the following: Carbamazepine, divalproex dr/er/sprinkle, gabapentin, lamotrigine, levetiracetam/ER, Oxcarbazepine, Phenytoin, Topiramate, valproic acid, or zonisamide."
You've got to be kidding me, right?  Aetna presumes to know more about my daughter's seizures than her own doctor... who also happens to be one of the top pediatric neurologists in the world?!  Where the hell did they come up with this?

So, at this point, it just so happened that we were going to UCLA that week.  I went back to Target, told Anna I'd work on it too, and got another 6 pills for another 3 days.  At UCLA, I spoke to Dr. Shields's nurse Sue, and she pulled her file, found the paperwork - realized it had been completed incorrectly by an intern - and said she would take care of it.  On a side note... Sue gave me a sample packet of Vimpat, so we were covered for 7 more days, assuming it would be no problem to reverse the denial.  And yet, another week went by and nothing changed... Vimpat was still being denied.

After Halloween, we were still getting denied, even with UCLA filing a second appeal.  We were getting down right desperate as I was literally going to Target every 3 days for 6 more pills.  Finally, I made a call to Aetna on my own.  I got a really nice man named "Bob" who said he understood my frustration, and could fix it in 5 minutes if only the doctor would simply call him.  Well, we were delayed a bit as Dr. Shields at his staff were out of town for a seminar.  6 more pills to hold us off.  I was seriously getting frantic.  We absolutely could not afford the $1,260 out of pocket payment for the drug.  I am so very grateful to Target for their patience and their help. 

Soon, we learned that the second appeal was denied.  At that point I called Aetna again and arranged a conference call with Nurse Sue.  I explained to Aetna that stopping the drug cold turkey would put Jenelle into status epilepticus thus most likely landing her in the hospital in the PICU... and how would they like to pay for that?  Further, stopping a drug that was already working, and that she had been taking for nearly 4 years might ruin the effectiveness of the drug.  Nurse Sue chimed in that Aetna's denial of this drug was literally putting Jenelle in a life threatening situation and that if the Aetna would not approve it, her only advice to me was to get an attorney.  What do you know?  Aetna listened, but not without insisting that Nurse Sue provide a letter from Dr. Shields stating that the situation was life threatening.  Two days later.. APPROVED!  Almost in time for her November refill!

Sue and I agreed... Target was the hero in all this.  They not only spent lots of time dealing with Aetna, but they continued to provided Jenelle with her mediation, even if I had to drive 5 miles out of my way every 3 days to get it.  I am a customer for life!

And I realize, I am fortunate to have health insurance through my employer, and to not have to worry about the cancellation letters people are getting right now.  The scary thing is that this is only the beginning of the changes we are seeing in health care because of Obamacare.  I truly feel sorry for my friends getting cancellation notices... and in my gut I know, things are not going to get better anytime soon.  OK, off my soap box. 

As for an update on Jenelle - she had a grand mal the early morning after Halloween, and then vomited later that day.  Her absence seizures are still unstable, but we are thinking the grand mal was due to illness as opposed to the other things going on.  Still waiting for the Video EEG to be approved... hopefully we'll hear something soon, unless Aetna has other ideas!

Thanks for the continued prayers!