Tag: insurance

Geezanages!

Pressha!

I have been on a medication for the past 12 years. It’s not an MS specific drug in the sense that it is not one that slows down the progression or anything but it is one of the few drugs on the market that targets a symptom (why can’t I ever spell this word on my first type? EVER!) of the disease. That symptom? walking! Soon after it was approved by the FDA, Gilbert and I talked about it, he wrote me a prescription and the rest is history. It’s a twice daily, extended-release pill so I take 1 at 8am and the other just before I go to bed. Some years ago when I was still on my favourite drug throughout this ordeal, Tysabri, and was still going to the MS Center of Atlanta (MSCA), a nurse practitioner suggested that I go down to once a day to see if I really had to keep taking 2. I did that for about a week, if so long, and that’s when I discovered that not only did the medication help my walking, but it also actually helped with my overall feeling of wellbeing – I went back to 2.

So yes, after a long 11 years or so, my relationship with the MSCA came to an end in 2020. Unbeknownst to me at the time I found them, closed my eyes and chose Gilbert to be my doctor, they had a partnership with another neurological clinic with which he was affiliated – I learned over the years and realized that this was the reason i could only see him on Tuesdays. Anyway, in 2020 I received a notice that the 2 institutions were parting ways and I could either stay with the MSCA or go with Gilbert. I actually decided to break up with both of them to support a black, female doctor whom I’d met at the MSCA and had started her own MS Wellness practice. Oh yes, this was perfect, I can support and get the care I need, even though it was a lil ways away from me. Well. I’m not one to complain but the first time I saw her, I actually told her about my experience with her staff – it was that bad…I won’t bore you with details but understand that I’m back with Gilbert at his other clinic! I have a really hard time dealing with incompetence and bullshit in my old age (except when it comes to my name…I just need to deal with that; nothing is going to change. I was actually referred to as “Stacey-Samuel the other day. LOL, that was a first but I digress)

I’ve often talked about my insurance and my realization that it appears to be quite good based on other stories I’ve heard. I really have no complaints especially after I completely understood the terms, how things work etc. That is until now…sigh! The prescription for that same medication above, has to be renewed annually and so at some point every year after I place a refill order (I have to refill monthly), I get a notice from the pharmacy that “we cannot fill your prescription without prior authorization from your insurance company. We’ve reached out; no action needed on your part” and a few days later, “your prescription is being filled and will be shipped on…”Well last month I got the “we cannot fill” notice…okay, no problem but then on March 10th, I got a notice that my insurance “denied the authorization for your prescription.” Wha?!? Action was now required on my part.

Forgive me if the next few sentences lil hard to follow…Sigh…between then and Friday gone, I’ve spoken to the insurance company reps, who’ve said that the issue has nothing to them – it’s the pharmacy, the pharmacy reps who have said that my request “needs additional review” what review? who can I talk to? no one, “they’ll” only speak to someone from your doctor’s office…I’m the kissmehass patient and they won’t talk to me! (this is my gripe to you, I didn’t actually say that to anyone) I told one man at the insurance company, “there must be someone that I can speak to (proper grammar be damned), u understand that the request was denied by my insurance; Aetna, you all.” He paused for a moment, I stupidly thought that I was making sense and some headway, and then said quite calmly and nonplussed, “I’ll transfer you to Caremark now” (the pharmacy). I hung up. On one of the days, I actually told the medical assistant at my doctor’s office “please don’t get tired of me but…”. She’s the one from whom I got the most information when she told me that they wanted additional doctor’s notes and, of course, she said that they were submitted.

At the point that it became critical, she told me that Gilbert wanted me to go down to 1 pill a day to stretch them out. I started doing that last Tuesday and it really sucks. My days have been going by in waves – I’ve been taking it in the morning so that I’m okay and can function alright during the waking hours but toward the end of the day and by the time I get in bed, I really don’t feel like myself and I just can’t put into words how I feel until maybe an hour after I take the next one in the morning. I’m also lethargic pretty much all day…Thursday, I found myself falling asleep in the middle of the workday at my desk – GASP! and that is completely unheard of. I was never someone who is against taking drugs but this one really seems to make a difference; I don’t think it’s mind over matter. I’m down to 6 tablets. Luckily because of a Facebook group of which I’m a member, I have a plan for if I run out that I’m going to set in motion today, but I don’t know if it will work and I’m not looking forward to running out completely. EVERYFRIGGIN thing is about money. Is Aetna tired of paying for this drug after all these years? I know it eh cheap. Are they thinking that it seems that I’ve been on it for all these years and I’m not walking on my own, so their investment is not paying off?? Is it simply that someone somewhere along the line, has not done their damn job??? steups

Anyway…stay tuned…

Method To My Madness

I don’t do anything willynilly (or at least most times I don’t); I prefer to be somewhat prepared – although I know anything can happen at any time. There is always method to my madness. In my last post, I talked about my vacationing, this time it’s about therapy.

as you know I’ve been going to Shepherd for therapy for a number of years. I don’t remember what my process was the first couple years but now I know that I’ll stay on the waiting list for about 2 months before they call me for my first appointment. It’s also no secret that I hibernate during winter cuz I absolutely hate being cold, so why in hell would I coordinate to go therapy anywhere between November and March? So my process is that I call and ask my doctor to write the script and start the ball rolling around the end of February. That would usually put my first appointment in May and I would be wrapped up by July (give or take a month or two)…but of course, that’s MY plan. I believe last year I had to wait bout 4 months to get the call. I actually remember calling shepherd to make sure that Gilbert et al had done as I requested and sent over the order. It was taking so long that I just knew that they forgot me. By the time I was done with therapy, there was almost no time for them to submit insurance claims. Insurance – that’s the other reason that I do what I do (as far as timing); I like to make sure that they have time within the same year to submit claims to the insurance company. As you can probably guess, the shit eh cheap and so every year, I max out my contribution to my Flexible Spending Account (FSA) so that I can pay for therapy without touching the money in my checking account.


let me explain. Every year in October, I can allocate up to 2600 of my paycheck to go into an FSA account that can only be used to pay for specific medical expenses as defined by Uncle Sam during the following year. Unfortunately one has to estimate the expenses for the upcoming calendar year to determine how much to put in. I love having it cuz I don’t have to use “my money” to pay for doctor visits, pills and other stuff but it kinda sucks because even though it’s my own money put into the account, if I don’t use it up, I lose it although it changed a few years ago and now I can actually roll over up to $500.

back to my method…if therapy is wrapped up by July/August, I should be receiving bills in the August/September timeframe right? At the very least by November, I should have paid Shepherd all their money and I’ll know how much is left in my FSA account and how to organise – I get new glasses and prescription shades every year to get that money down as necessary. Back to last year…everything took so long that I ended up making a balloon payment on December 30th (without actually receiving a bill) cuz I wasn’t trying to lose any of my hard earned money – remember they only allow u to roll over $500.

this year, I knew I was golden. Therapy wrapped up in august;I knew I’d get my bills and they’d be paid; I wouldn’t have the angst from last year. Wouldn’t you know it, I’ve only gotten one bill for a little over 200 thus far. Steups. I’ve called to find out what the problem is and each time I was told that “they have a new system and things changed so everything’s taking a little longer” and “no ma’am, u don’t have a balance.” Double steups. Whattheheck. I can’t believe that I’ve been hounding an institution to friggin pay them! The one saving grace that I have this year is that I now know that I have till March 31st of next year to use the money but I would rest easier if I could just pay them and be done. Sigh…at last check i still have a little over $1400 in my account.

Hol’ it down – I gone so..

Insurance Claims

so i got a notice in the mail from Dekalb Medical which is where i went the last time i fell.  the notice stated that it had been 30 days and they hadn’t heard from Aetna as yet re:payment.  The balance on the account was somewhere between $1500 and $2000 (for a CT Scan) but when i looked at the bottom line “Pay this amount” it was 0.00 so i breathed a little easier.  well that prompted a call to Aetna to find out what the problem is!

First thing i did was check my claims online and sure enough i saw that it was denied – great!  Anyhoo, so i made the call.  Come to find out that it was denied because it wasn’t pre-certified (approved) by Aetna…and then the lady said if it isn’t pre-certified the only time it might be paid is if the doctor diagnoses it as an emergency.  So i said, “well it was an emergency – i’d fallen and was in the ER.”  i was told that since i was coherent I should have told the ER nurse/doctor to make sure and pre-certify the scan before anything was performed.  I told the woman that that was the dumbest thing i’d ever heard.  I mean who has time to think about those issues when u are in an ER and worried about whether or not you’ll come out in 1 piece or what they are going to tell is going on in that body.

while she was spouting off at the mouth, i continued looking at my claims and noticed yet another 1 was denied – the last MRI.  i asked her about that one – and again she told me that it wasn’t pre-certified.  Now that, i’m mad about.  The MSCA had no business doing it without it’s being pre-certified – they ALWAYS do it.  Now y they wouldn’t do that this year?  who knows! 

On the upside, i haven’t gotten any bills from either place (YET?!?)…so I haven’t gotten my panties in a bunch or putting on my armour to go to battlle with anyone – YET!!!

Whoa!

I’m not complaining – I swear i’m not (u all know that i of all people am not)…but 70degrees in FEBRUARY!!??!!!  the world is coming to an end – what the?!?!?!  of course, next week it’ll probably snow – such is the weather in Atlanta – steups!! (sorry folks, i have no idea how to translate – it’s a teeth sucking noise that we Trinis do)

Anyhoo, I’ve said before that sometimes i think that insurance is 1 of the biggest ripoffs ever.  But boy am i thankful for it.  My mother is an Executive Agent at Guardian Life and many good things have happened to her since working at Guardian Life and she is doing extremely well there – extremely grateful for that!  Yesterday i got a bill for my last infusion in the mail.  My copay is $40 on the day of and then i normally get a bill for 4.79.  Yesterday when i opened the bill, it was 23.95 – so, of course i needed to understand y it had jumped so much all of a sudden. and i logged onto the insurance co website.

well i discovered that by the time i’d started infusions last year, i’d already met my deductible for the year – hence the low bill (I’d spent so much on my health last year).  Of course i haven’t done anything for this year as yet, so i have to meet my deductible before anything insurance kicks in.  Okay, i can live with that.

Then i saw the actual cost of the infusion – 5032 big ones every month!!  EVER GRATEFUL for the INSURANCE!!!!!!  how do sick people without it deal?  I guess they just deal with their ill health???  There was NO way that i could pay $5k monthly; i’d have to do an infusion a  year or something.  Maybe for sick people, insurance is not a the biggest ripoff afterall
🙂

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