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Old 02-15-2013, 05:29 PM   #1
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Insurance companies are evil Update post 24

My husband has decent insurance through his employer...

Well they changed what they cover on the 1st of the year and didn't give us any notice whatsoever.

He takes 2 drugs for anti-rejection (kidney transplant)...cellcept and prograf.

Well beginning Jan 1 they decided they're not covering Prograf anymore.

This means one of three things.

1) We're working with the transplant center, they're going to try to work with this mail order pharmacy so we can get the prograf for our regular copay ($80 every 90 days)

2) He has to switch to generic, this means three times a week blood draws for 6-12 weeks...followed by bi-weekly blood draws until the 6 month mark and then monthly blood draws for the rest of his life.

or

3) We can't get the name brand, the generic fails and he rejects the kidney and dies.

The bill for the name brand is $550 a month....if we live in our van or stop eating we can swing it...but I'm not a fan of homelessness...it gets cold in Iowa....and for some unknown reason my kids expect to be fed semi-frequently...


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Last edited by MamaNae; 02-16-2013 at 12:15 PM.
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Old 02-15-2013, 05:36 PM   #2
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You should be able to get a prior authorization for it. You might have a higher copay, but it should be covered. I worked as a tech for 4 years- we dealt with ins issues like this all the time. It requires a lot of legwork, calls, paperwork, etc but usually it gets processed through
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Old 02-15-2013, 05:40 PM   #3
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Re: Insurance companies are evil

We tried, our pharmacist tried, the transplant center nurses tried and even the physician called and yelled at them. Nothin doing.

The new 'copay' is $550 a month.
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Old 02-15-2013, 06:38 PM   #4
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Re: Insurance companies are evil

If the generic doesn't work for him they should cover name brand. It might mean that he has to try it instead of just a letter from the doctor. Also, he should check with the benefits coordinator at his work and see if they can help. Maybe they can get it added back to the plan if they inadvertently took it off.
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Old 02-15-2013, 06:55 PM   #5
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Re: Insurance companies are evil

TRYING is stupid and reckless and incredibly dangerous. Trying the generic, since it's a different formula, has a very, very high chance of sending him into rejection...which would kill him. I'd rather not 'try' something that has a 60% chance of killing my husband...

He called the benefit specialist, she says they didn't change anything, the change is with BCBS.
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Old 02-15-2013, 06:58 PM   #6
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Hugs, my sister had a liver transplant at age 8 and takes both those drugs. I'm sorry you're going through this. Big hugs!

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Old 02-15-2013, 07:06 PM   #7
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Re: Insurance companies are evil

I'm emailing media, called Senator Tom Harkin and called every kidney patient advocacy group listed on this form the transplant center gave us...left messages of course considering the time but the transplant center is giving us 1 week of medications (have to drive to the city tomorrow to get it) so I can wait until Monday.
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Old 02-15-2013, 07:13 PM   #8
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Didn't read everything, but just wanted to add this:


My mom has sent an "appeal" letter before and insurance has reevaluated and then covered a procedure that they originally denied. She threatened to inform someone or some organization. I can't remember. :/
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Old 02-15-2013, 07:14 PM   #9
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I hope it gets straightened out. I can only imagine how scary this is for y'all.
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Old 02-15-2013, 07:19 PM   #10
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Re: Insurance companies are evil

Quote:
Originally Posted by MamaZnR View Post
Didn't read everything, but just wanted to add this:


My mom has sent an "appeal" letter before and insurance has reevaluated and then covered a procedure that they originally denied. She threatened to inform someone or some organization. I can't remember. :/
DH filled out their appeal form...we'll mail it off tomorrow. And inform them on Monday of all the calls we made over the weekend (State senator, every news station in central Iowa, newspaper)

I am huge fat and pregnant, and we have 3 adorable kids....they don't want their cute faces on the news crying about their daddy being sick
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