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Note to insurance companies: Not all meds are created equal

Submitted by on Wednesday, 12 January 2011 No Comment

Stop me if you’ve heard this one before – and if you have a chronic medical condition, you probably have.

One drug works so-so, or not at all to control your symptoms. This is the one that’s on your insurance company’s formulary, the “mother may I” list of what is and isn’t covered.

Another works remarkably better, so much so that you barely even know you’re sick. That one, of course, is not on your formulary.

So who’s really deciding your treatment, your doctor or your insurance company? The answer’s pretty obvious.

I’ve done this dance before, when we were civilians. Until about a year ago, Singulair was one of the antihistamines Big Guy took regularly. It also was the one that worked best, and it had the added advantage of alleviating both his asthma and his allergies. The insurance company we had when it was first prescribed covered it. The second didn’t, and after requests for coverage from two doctors were rejected I paid out of pocket to the tune of $6o a month. At least I had that option back then.

Fast forward to 2010, when Big Guy had a terrible, yucky awful autumn. The highlight was two trips to the emergency room – the second would have been unnecessary had the first doctor not blown the diagnosis – and a week off school.

When we went to see his allergist a few weeks later, the doctor suggesting trying a different asthma medication. He gave us a sample of Advair HFA – that’s the inhaler version – along with a prescription, and we were off.

Advair worked like a charm. In a matter of a week, Big Guy went from chronic mucus with the occasional wheezing or chest tightness to as good as new. Asthma’s like that. What had worked before will suddenly quit, and you’re be back to the drawing board.

When I went to fill the prescription, though, it was back to the drawing board again.

Advair HFA is not on the formulary, they said, and the pharmacy no longer asks to exceptions to policy because they cost the Army too much. I couldn’t even pay out of pocket because the pharmacy doesn’t  stock it.

I did have options, none of which was particularly helpful at the moment. I could get it via the mail prescription service, which takes at least a week turnaround time, or I could take it to a retail pharmacy, the closest of which is 35 miles away.

Even though Big Guy had only a few days left on his sample inhaler, I opted for the mail service. Long-term, that’s better than a 70-mile round trip once a month. Short-term, we could switch back to his old medication until the Advair arrived.

It all makes me wonder once again why people gripe about managed health care when we already have it – it’s managed by accountants. And it gives me nightmares when I think of what could happen if the Republicans manage to repeal the new health care law and we return to a system that didn’t work well to begin with and was deteriorating rapidly.

Copyright 2011 Debra Legg. All rights reserved.

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