Restasis/Cyclosporin

[k9krap]

I received a call (and text) from Dr. Church’s office, saying my insurance company has notified them that they no longer cover these drugs.  I have received no notification of this fact!  And, they asked me to contact them to find out what drug they will cover!    WTF?  I Have never had a doctor ask for this.  I have no idea what other drugs are available to treat my conditions and how they interact with other drugs I’m using. This is absolutely insane!  Right?

ETA:  I just received a refill this week (3 months worth), at a $5 copay, which probably spurred this.   Plus, I get at least 4 applications from each vial, which means this will last a year.  And I have a few more years’ worth stowed away.  (Thank goodness I didn’t pass on this refill, as I thought about doing!) So there’s no rush to resolve this.  It’s still maddening.  

[Dave's Not Here Man]

Keywords: medically necessary

[minx]

You have BC/BS, right? If so, I call bullshit. They just don't want to jump through the extra hoop to do the approval form.

And unfortunately, his office staff are assholes so they won't tell you why BC is refusing coverage. If you wanted to push it, you could call their office, point out that BC does have this on their list of covered medications and you need the exact reason for their rejection, along with what Dr. Church submitted so you can appeal their decision.

I have to get my Lunesta approved every year, and while it pisses me off that they require this, I have NEVER had any issue getting that authorization.

Finally, what the fuck is up with asking YOU to recommend a new prescription?

I say pitchforks at dawn. Who's with me?

[k9krap]

Yeah, I was thinking about this last night and they do have to get authorization every year. I think my current authorization expires in May. But, that was for Restasis, which is the non-generic brand. I thought I was safe (and much much happier! Copay is 20 times cheaper!) when Dr. Church switched me to the generic cyclosporine. But I guess it’s all the same.

But your last question is what got me - how do I know anything about that?

And Jon, dry eyes can cause blindness so to me, that is medically necessary. I nearly flunked a DMV eye test (and would have if a clerk hadn’t helped me cheat) years ago because one of my corneas was fucked up from dryness.

[Dave's Not Here Man]

So what I have done in that situation is call the insurer and inform them of that fact and say you want to escalate an appeal. Helps if the provider offers to call them, but not all practices are built that way (helping with prescription pre-authorizations). Don't think we've ever had any more issues getting covered once I made that call.

[k9krap]

I’m just so fucking tired of fighting every fucking thing. Every day it’s a fight. I’m exhausted.

[minx]

I 100% say that insurance should not be the gateway between care that your doctor thinks is needed and what gets covered.
The only exception I would make is for medications being prescribed for off-label use, or procedures that in no way shape or form match the diagnosis submitted. (a MRI of the head for leg and foot pain for example).

But Pam's example is for a medication that is the most commonly prescribed for her stated diagnosis, AND it's the generic form of it. Asking for prior authorization is asinine.

But the Drs behavior is even more asinine. And I will say that he 100% doesn't have much to do with it. Which is a whole different problem - his office staff refuse to let you talk to the doctors without an appointment, which may or may not be covered by insurance.

I've been looking for a new Ophthalmologist. Haven't found one yet.

[Dave's Not Here Man]

Its two phone calls. Okay maybe 3 since you know one of them is going to get dropped in the middle of you explaining their problem. If you need that stuff grab your big girl pants and make the calls.

[k9krap]

I have my first tri annual visit next month. I’ll bring it up then. Like I said in the OP, I’ve got a few years of doses saved up.

I was just surmising a few days ago about how well my current regimen is working, as I seldom need to use rewetting drops now. Of course, I’m taking 4 supplements, using 4 different eye drops and hot compresses daily.

[minx]

Ah, sadly the insurance company will do nothing without a doctor's authorization. And it sounds like these guys didn't even try, and aren't interested in trying.

[k9krap]

Got the letter today. And, yes, under the Medicare portion of my coverage through Blue Cross, cyclosporine is no longer covered. And, they only provided one month of it this time. Grrrrr. So now I need to request an exemption or find another drug to replace it. Okay. It’s clear now.

[minx]

Maybe to you!

Medicare doesn't cover prescriptions. So why is it denied under both?

[k9krap]

I’m done with it. I was going to quit Restasis because of the expense, even with the insurance coverage, a couple years ago. Once my stock is depleted, I will no longer use it. That leaves just one prescription they are covering.

[minx]

Unless the prescription is completely off the wall experimental (as a poor excuse, let's say using penicillin to treat dementia), then it should be covered if prescribed by a licensed medical professional at the recommended dosage or below.

I can see asking for justification if the amount prescribed is over the FDAs recommended dosage, but that's about it.

[k9krap]

If you recall, several months ago, BC/BS informed me that they were switching me to their Medicare supplemental plan but it would cost me no more and I would see no changes to my benefits. I believe this is one of the repercussions for that switch.