Playing by the rules, stuck with the bill (Part One)

With having a limited income, I am constantly checking to make sure doctor visits, procedures, tests, medicines and other services are covered by my insurance. If find out something is not covered, I will cancel the service.

Last fall, my doctor prescribed a medication which was instantly denied by my insurance. I was not diagnosed with the medical condition needed for my insurance to cover the drug. My doctor then resubmitted the request and added medical records (and the appropriate diagnosis) needed to get the medicine covered by my insurance. The information and second request were sent to a speciality pharmacy.

The speciality pharmacy called me and told me my medication may not be covered by my insurance. They would work on the paperwork and try to get the drug covered. I was informed of the price of the drug and nearly had a heart attack! If my insurance denied drug coverage, there was no way I could afford to pay for the drug out of pocket.

A week later, I received a phone call from the speciality pharmacy. Good news, my insurance was going to cover the cost of the drug. My responsibility would be zero dollars. Hooray! What a blessing. The specialty pharmacy sent out the drug.

Five weeks after receiving the drug, I receive a letter in the mail. My insurance notified me that they were denying coverage of the medication. Under their guidelines, I did not qualify for the drug. I immediately stop all refills of the medicine.

I notify my doctor about the insurance issue. She assures me the medicine can be covered by my insurance. She submits another prescription. The specialty pharmacy attempts to process the request; however, there seems to be an insurance issue. The prescription is not filled.


(Part a Two click here)