Opinion

Opinion | Elissa Ely

Trying to navigate the cold, confusing health insurance maze

FILE - In this Friday, July 8, 2016 file photo, a prescription is filled at a pharmacy in Sacramento, Calif. On Friday, May 11 2018, Trump is scheduled to give his first speech on how his administration will seek to lower drug prices. (AP Photo/Rich Pedroncelli, File)
Rich Pedroncelli/Associated Press/File
A prescription is filled at a pharmacy in Sacramento, Calif.

If you are young and on medication, and the approval of your peers is your life nutrient, then an unsightly side-effect — in this case, drooling — is unacceptable. Fortunately, there is a common and generic treatment; according to GoodRX, it costs $23 a month. I phoned it into the patient’s pharmacy.

A day later, the pharmacy called: Insurance had rejected the claim. I called the insurance line and spoke to a pleasant representative. She explained that my patient would need to try three other medications for peptic ulcer disease first.

The patient didn’t have peptic ulcer disease; she had schizophrenia. Salivation was a side-effect of the only drug that had helped her. I filled out a Prior Authorization form with details.

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Forty-eight hours later, the claim returned: rejected.

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I called and asked to speak to the medical director. This is not permitted, so I was connected instead to a supervisor, who suggested three alternatives to the peptic ulcer disease my patient did not have.

I faxed a letter with articles attached; though it is not FDA-
approved, the side-effect drug is widely used.

Forty-eight hours later, the claim returned: rejected.

I called, asked to speak to the medical director, and was connected instead to a senior pharmacist. He was knowledgeable, interested, and seemed to be taking notes. I explained that if the patient couldn’t stop drooling, she would simply, and sensibly, stop all medication. Then she would be re-hospitalized for psychosis, costing the insurance company many thousands of dollars, instead of $23 a month. The pharmacist said I was not permitted to speak to the medical director — it was a company mantra by now — but he would present the case himself and get back to me in a day or two. Sure, I said. Bridges have been sold for less.

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But a day later, he called. Good news, he said, sounding overtly professional and covertly pleased. The medical director had approved an override.

I wanted to pump his hand through the phone line, hand him a cigar. I felt like I had given birth.

Just before we hung up, it occurred to me to ask what the co-pay would run. Generic medications usually cost a couple of dollars. My patient could afford this, though not $23 a month.

“Let’s see,” he said, rustling an invisible list, murmuring himself through it. “Tier 4 override, non-FDA approved.” There was a pause while he got the numbers straight. “The monthly co-pay for this medication,” he said, “will be $90.”

It was not his doing. Human responsibility in these moments has become untraceable. The medical director might have had an explanation. No one could find him.

Elissa Ely is a psychiatrist.