Early last year, I was having some mental health drama. I was frequently anxious, needlessly driving myself nuts with worry, and basically felt desperately out of control for no apparent reason. I felt like an outlet with pent-up electricity and no outlet for it.
I made an appointment with my primary care doc to tell her that the meds were no longer working. At the time, I was on Prozac and had been for the last 10 years.
My doc switched me to duloxetine, which is generic for Cymbalta. She initially started me on 40mg and, after a month, upped it to 60mg.
I started seeing a psychiatrist after waiting three months for an appointment. On my 3rd visit, she upped the duloxetine to 80mg. Duloxetine only comes in doses of 10, 20, 40, and 60, so she prescribed two 40mg pills a day. Easy math, right?
Things eventually evened out, and I was feeling good for a while.
In October, my employer changed insurance companies from Anthem to Humana.
Having once worked for Humana as one of the people on the phone explaining to members why their claims were denied, I already had a dim view of the company. I hated that job so much that I peaced-out in the middle of the day. I can only take so much of breaking people’s hearts.
Prior to the change, I checked all my providers, and they all accept Humana. I figured all was well. Then it came time to refill my duloxetine.
A text from CVS notified me the refill request was canceled. I checked with my doc to ensure she had sent in the refill request, and she had. Then I thought maybe they tried to process the claim against the old insurance, so I went up to the store to give them my new card.
“We already have Humana on file,” she noted.
Perplexed, I asked, “How can you have it on file when I’m just now giving you the card for the first time?”
She said something about insurance companies or doctors passing along changes to insurance coverage automatically. I was skeptical and found that news somewhat creepy. How would Humana know where I get my meds if I never told them?
Anyway…that answer was ultimately unhelpful. I shook the wonderment from my befuddled brain and asked, “If you have the new insurance, then why is my refill not being processed?”
The kind pharmacy technician clickity-clacked at her computer and then printed out a claim denial from Humana. The denial explained that the prescription wasn’t covered, but had a “helpful” list of alternatives. The list of alternatives consisted of different doses of duloxetine. Apparently, Humana only covers duloxetine in 10mg, 20mg, and 60mg doses. Since my prescription was for 40mg pills, it got denied.
My psychiatrist had to change my prescription from two 40mg pills to 60mg and 20mg pills. After she did that, the claim was successfully processed, and I finally got my meds…after having been without them for days because Humana is run by a bunch of assclowns.
The next time I saw my primary care doctor, I was telling her about this entirely imbecilic debacle, and she went off on a (totally legitimate) tangent about insurance companies and how they have too much control over patient care. She then apologized for ranting to me about it.
She wasn’t bothering me at all. “You’re preaching to the choir. Rant away,” I told her.
It’s absolutely stunning that a trained medical professional, someone with years of medical school and real-life experience in the medical field, can have a treatment denied by some douchelord who has never had a day of medical training in his or her life.
Health care in the US is broken. It took me until this month to pay off the thyroid cancer treatments I received in early 2020. That’s nearly three years and thousands of dollars (even after insurance covered their part) to keep my dumb ass alive. I could not have afforded to stay alive if I didn’t have a decent job.
I’ve seen firsthand what that medical debt can do. My mom had a triple bypass in 2010 and was still making payments on it when she passed in 2019 because she could only afford to pay about $50 a month and owed them more than $10,000. She was constantly nagged by billing. Can you pay more? No, Karen, she can’t. She worked at Walmart. Then, after she retired due to medical reasons, she was on social security, which meant she was working with much less.
I don’t know what the answer is. Medical billing, insurance, and universal healthcare are things outside my expertise. It doesn’t take an expert to recognize that things are fucked up, though.
Something has got to give.
Yeah, the way the system works is that insurance companies hire and pay probably tens of thousands of people to make sure sure they pay out as little as possible, and the hospitals and doctors hire thousands more to try to squeeze as much reimbursement as possible from the insurance, the insurance tries to outplay them, they try to outplay the insurance, and the loser in these stupid games is anyone who pays extra money insurance premiums or medical bills to cover all this essentially useless work.
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Kinda stupid, isn’t it?
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