Ok, here is what happened. I have like the worst insomnia ever. My doctor has tried everything and about a month ago my doctor prescribed the new sleep medicine Rozerum. It totally worked, and nothing had ever worked except for tranquilizers and sedatives that made me feel like a zombie. So finally my doctor found me this awesome medicine that helps me sleep and doesn't make me feel like the living dead. Then the insurance company calls and says that medicine isn't on their list. So now I can't take it anymore and my doctor is gonna have me back on some effing narcotic and I feel so screwed!
2006-11-04 14:48:34 · 19 answers · asked by guitarusa2001 1 in Business & Finance ➔ Insurance
My family can barely afford to live, much less afford medication. If I wasn't given mine for free I'd be a dead woman.
2006-11-04 15:08:48 · update #1
Yes they can and yes they suck for doing this, but, that's the sorry state of health care in our country today.
Call your doctor, explain the situation, and ask him/her to help you fill out the forms that you can download and print out from the web site for the Partnership for Prescription Assistance. This organization is a godsend. They are a liasion between you, your doctor, and the pharmaceutical company that makes your medication, and, in many cases, can help you get your meds at little to no cost. They helped me get my migraine medication - Imitrex - when my insurance ran out, for free, which saved my life because the doses cost $30 each and it was way out of my league to pay for out of pocket. You have to do the initial legwork on getting the forms, but, your doctor should be able to step up to the plate and help you out while waiting for the approvals, by providing you with samples, which they get for free from pharmaceutical salespeople. My doctor had a drawer full, I kid you not, and was able to give me a few to tide me over. Be assertive, be thorough, be diligent, and don't give up. DO NOT GO BACK ON THE USELESS NARCOTICS. You will only do yourself more harm than good, as you already know. You have to be your own advocate here, as no one in our current government is gonna speak up for you. Don't forget to vote on Tuesday, against every single incumbant who has failed to make affordable health care a reality for us average Americans.
2006-11-04 16:04:33 · answer #1 · answered by happy heathen 4 · 0⤊ 0⤋
The insurance company will pay for the treatment or drugs specifically listed in the governing policy or their official list of covered drugs. If your treatment or drug is not listed, it's not covered.
However, like many have already stated, you can look to see if their is in alternate. You can also have your doctor contact the insurance company to see if you can reach an agreement where you can get the medication you need and they will pay up to the allowable for an alternate medicine. For example: Med ABC is on their list for insomnia. Med XYZ is not, but XYZ is the only one that will work for you. See if the insurance will pay out what they would have paid for ABC when you go in and get XYZ. Okay, that may not have helped, but hopefully you understand what I am trying to say. Your doctor will know how to "work the system".
2006-11-05 01:49:33 · answer #2 · answered by Karen T 3 · 1⤊ 0⤋
You need to go back to the insurance company, and appeal the decision.
There are two different people who review claims at insurance companies - the robots, and the thinkers.
The first set of denials are always from the robots - they just look at a list, and if they can't find it, they send the denial. Then you have to appeal. Your doctor will probably have to write a letter saying there isn't anything comparable on the market, and that you need this, and your insurance is likely to pay after the appeal.
2006-11-05 00:57:03 · answer #3 · answered by Anonymous 7 · 1⤊ 0⤋
Yes- they can and they do. Insurance companies are a big big problem in American society. I work in health care and I am a single parent, so I see both sides of healthcare - and the insurance is the bad guy in nearly all problems. Sometimes, the doctor can write an appeal explaining why this one particular medicine is the best for you, and they might approve it.
2006-11-04 14:54:29 · answer #4 · answered by HearKat 7 · 0⤊ 0⤋
The insurance company can do this; controlling access to medications and health care providers is one way insurance companies control costs and keep health plan prices lower. You can go to your doctor and see if she/he will support you if you appeal the claim decision. Then go back to your insurance company and try again.
If you can’t get help through your insurance company, I’ve included links to a couple of Web sites that have information on prescription drug assistance programs.
From a fellow insomniac,
Barnes@MostChoice
http://www.mostchoice.com/health-insurance.cfm
2006-11-08 06:55:14 · answer #5 · answered by Anonymous · 0⤊ 0⤋
Yes they can, but that doesn't mean you have to go back to some medication that doesn't work. Talk with your doctor or find a new one and see if he'd be willing to continue to give you the samples of which he probably has more than enough. I'm sorry this happened to you -- unfortunately, medical insurance is a racket.
2006-11-04 14:53:15 · answer #6 · answered by Anonymous · 0⤊ 0⤋
Depending on how much your prescription is out of pocket, Ameriplan might be able to help you. They are a company that helps people who do not have and need affordable health benefits. Their basic dental package includes all dental care, surgery, orthodontics as well as prescription, vision and chiropractic benefits. There's no high premiums, deductibles, co-pays, waiting periods, or anything like that at all. They can save you up to 80% on your out of pocket expenses for less than $12. If your prescription is expensive and you don't have dental benefits, this could be something that could really help you. Try this website and you can check out the specifics and providers in your area. http://www.everyonebenefits.com/40424269... They are a wonderful company and are members of the BBB. I have benefits through them as well. Hope you find what you need. Please email me if you have any questions, and I'd be happy to help you if I can. Best of luck.
2006-11-07 12:17:32 · answer #7 · answered by Anonymous · 0⤊ 0⤋
Yes, but under the terms of your policy, they are not screwing you. I would suggest you speak to your doctor and see if there is a generic or substitute that will be covered. Check at work to see if there are alternate health care plans (some companies offer a choice of two or three) that may cover it.
Also check with your company to see if they offer a Flexible Heath Account. They tax pre-tax dollars and allow you to set them aside tax-free for certain health care purposes, one of which is non-covered scripts.
2006-11-05 01:10:45 · answer #8 · answered by jerry 5 · 1⤊ 0⤋
Unfortunately, yes, they can do this.... If it's not on their formulary, they don't have to cover it...
BUT - if you doctor can prove that is the only medication that works for you and can document that you've tried their "preferred" ones over an extended period of time, they might relent and cover it.
If that fails, contact the company who makes it and tell them it's not covered by your insurance and can they help you out? Often, they can send samples for you to your doctor's office (laws sometimes prohibit them sending them to the patient directly) or send you coupons for freebies.
Good luck!
2006-11-05 00:34:08 · answer #9 · answered by zippythejessi 7 · 0⤊ 0⤋
find out if the make of Rozerum and see if they have a program I know that Astra Zentica drug company I think that is how you spell it has a program that would enable you to get their medication on ether a cheaper price or I think maybe even free in some cases kind of like Fin. aid
if you have ???? check back with me
2006-11-07 13:22:36 · answer #10 · answered by rahnside 2 · 0⤊ 0⤋