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Topic Resolution of Rx problem Go to previous topic Go to next topic Go to higher level

By lurkingforacure On 2009.10.08 16:19
I am posting this separately so everyone can learn from our experience. Read my thread on "peer to peer consult/conference required for Rx" for the background.

The latest: today we had our regular three month appointment with our neuro. You may remember Humana had told me on the phone that our doc would have to have a peer to peer conference with Humana's doc to see if Mirapex, which we have been taking for over three years now, was still "medically necessary". Yes, I also wonder just how many PD patients suddenly no longer need this med or that..

Turns out, humana never gave our neuro that courtesy. They sent him a form to fill out, which he did (note: there was NO place on that form where he could write that we had already tried Requip unsuccessfully). He never did get to talk to anyone, the form he filled out and sent to them was immediately rejected without any discussion whatsoever.

Sooo, our neuro got pissed this morning reading through the forms, and called them while we sat in the room with him. He left a rather terse, you better issue this script or this man's blood is on your hands, kind of message. I intended to follow up with my own phone call to Humana once I got home with the kids and had a moment to do so. Oh, we left his office with a ton of samples, since we had no idea how long this thing would take to resolve, a bonus I guess.

Lo and behold, as we are walking in the door this afternoon, the nurse calls to tell me Humana has approved the script and the approval would be submitted to the pharmacy tomorrow. Our neuro told us he had never, ever seen this kind of thing happen before, to anyone, for any med. His nurse, however, told me she has seen this before, and it was with Humana as well. They are building up a reputation, it would seem.

So it ends well, but look at what all we had to do, and how much extra work our doc had to go to. You really have to persevere. Thank heavens our neuro stuck with us and helped. Now I'm feeling guilty about all those samples we don't need! I guess we save them for a rainy day in case this happens again next year.

By lurkingforacure On 2009.10.13 18:42
And the final letter from our insurance, which we received today, THANKING our neuro for the "valuable opportunity to review our original determination." I am not kidding.

This is only topped by the fact that the reviewing doc of my husband's medical file for our insurance company was an OB/GYN. I love it. At least the damn script got approved....but only until May, 2010. Then we get to do this all over again, but at least this time, I have a much better idea of what is going on.

By annwood On 2009.10.13 19:09
You got to love those insurance companies. They create havoc to justify their existence.

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