I am currently taking Xyrem, and it seems to be working fairly well for me so far. I started on it in February, and in March (unbeknownst to me) my health insurance company reclassified it as a "Specialty" drug. When I started it, it was classified as a "retail" formulary drug, and I had a flat-rate copay of $25; now as a "Specialty" drug, I am being charged 20% of the total cost, which now means well over $100/month for me. I was informed by the pharmacy that this change had occurred, not by the insurance company! (I called my insurance company, though, and they confirmed what the pharmacy had told me was true.)
Has anyone else had a similar experience with their insurance company? If so, how did you handle it? Does anyone know if I have any recourse in this situation? I want to appeal the insurance company's decision, but I'm not sure how to go about it (especially while trying to resist my compulsion for profanity). I'd hate to stop taking it simply because of the cost, but I'm not sure if I can afford it now, and the pharmacy says I don't quite qualify for assistance.
Any advice is welcome & appreciated.
Thanks!
~Heather
Xyrem - Problems w/Heath Insurance company?
Started by
daveislate
, Apr 29 2008 09:26 AM
5 replies to this topic
#2
Kimberly
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Posted 30 April 2008 - 09:24 PM
Hi Heather,
Call the customer service number on the back of your pharmacy insurance (or medical insurance) card, and ask them what the procedure is to file a grievance.
The words "appeals" and "grievances" are taken very seriously by health insurance companies; as most have to abide by state law with regard to responding to formal complaints from members.
Another option would be to contact your state's Department of Insurance to file a complaint.
I would probably contact the insurance customer service first, ask for the grievance procedure, try to go through that, before threatening to take the complaint to the state DOI. If you do mention the DOI, the insurance company should snap to it and at least review your grievance!
If the formulary change was from one plan year to the next I would say it is probably your employer group's responsibility to notify you of the change. It is very common for formularies to change from one plan year to the next for cost-saving purposes. I have also seen formularies change on the Medicare Part D plans, but it is also normally from plan year to plan year. Changes during the plan year seem odd to me, especially for a drug like Xyrem that is probably taken by so few people that the least they could have done was send a letter to everyone who had a Xyrem prescription filled in the past 6 months!!
Hope this helps.
Call the customer service number on the back of your pharmacy insurance (or medical insurance) card, and ask them what the procedure is to file a grievance.
The words "appeals" and "grievances" are taken very seriously by health insurance companies; as most have to abide by state law with regard to responding to formal complaints from members.
Another option would be to contact your state's Department of Insurance to file a complaint.
I would probably contact the insurance customer service first, ask for the grievance procedure, try to go through that, before threatening to take the complaint to the state DOI. If you do mention the DOI, the insurance company should snap to it and at least review your grievance!
If the formulary change was from one plan year to the next I would say it is probably your employer group's responsibility to notify you of the change. It is very common for formularies to change from one plan year to the next for cost-saving purposes. I have also seen formularies change on the Medicare Part D plans, but it is also normally from plan year to plan year. Changes during the plan year seem odd to me, especially for a drug like Xyrem that is probably taken by so few people that the least they could have done was send a letter to everyone who had a Xyrem prescription filled in the past 6 months!!
Hope this helps.
QUOTE (daveislate @ Apr 29 2008, 09:26 AM) <{POST_SNAPBACK}>
I am currently taking Xyrem, and it seems to be working fairly well for me so far. I started on it in February, and in March (unbeknownst to me) my health insurance company reclassified it as a "Specialty" drug. When I started it, it was classified as a "retail" formulary drug, and I had a flat-rate copay of $25; now as a "Specialty" drug, I am being charged 20% of the total cost, which now means well over $100/month for me. I was informed by the pharmacy that this change had occurred, not by the insurance company! (I called my insurance company, though, and they confirmed what the pharmacy had told me was true.)
Has anyone else had a similar experience with their insurance company? If so, how did you handle it? Does anyone know if I have any recourse in this situation? I want to appeal the insurance company's decision, but I'm not sure how to go about it (especially while trying to resist my compulsion for profanity). I'd hate to stop taking it simply because of the cost, but I'm not sure if I can afford it now, and the pharmacy says I don't quite qualify for assistance.
Any advice is welcome & appreciated.
Thanks!
~Heather
Has anyone else had a similar experience with their insurance company? If so, how did you handle it? Does anyone know if I have any recourse in this situation? I want to appeal the insurance company's decision, but I'm not sure how to go about it (especially while trying to resist my compulsion for profanity). I'd hate to stop taking it simply because of the cost, but I'm not sure if I can afford it now, and the pharmacy says I don't quite qualify for assistance.
Any advice is welcome & appreciated.
Thanks!
~Heather
#3
TJStarnes
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Posted 01 May 2008 - 07:15 AM
QUOTE (Kimberly @ Apr 30 2008, 09:24 PM) <{POST_SNAPBACK}>
Hi Heather,
Call the customer service number on the back of your pharmacy insurance (or medical insurance) card, and ask them what the procedure is to file a grievance.
The words "appeals" and "grievances" are taken very seriously by health insurance companies; as most have to abide by state law with regard to responding to formal complaints from members.
Another option would be to contact your state's Department of Insurance to file a complaint.
I would probably contact the insurance customer service first, ask for the grievance procedure, try to go through that, before threatening to take the complaint to the state DOI. If you do mention the DOI, the insurance company should snap to it and at least review your grievance!
If the formulary change was from one plan year to the next I would say it is probably your employer group's responsibility to notify you of the change. It is very common for formularies to change from one plan year to the next for cost-saving purposes. I have also seen formularies change on the Medicare Part D plans, but it is also normally from plan year to plan year. Changes during the plan year seem odd to me, especially for a drug like Xyrem that is probably taken by so few people that the least they could have done was send a letter to everyone who had a Xyrem prescription filled in the past 6 months!!
Hope this helps.
Call the customer service number on the back of your pharmacy insurance (or medical insurance) card, and ask them what the procedure is to file a grievance.
The words "appeals" and "grievances" are taken very seriously by health insurance companies; as most have to abide by state law with regard to responding to formal complaints from members.
Another option would be to contact your state's Department of Insurance to file a complaint.
I would probably contact the insurance customer service first, ask for the grievance procedure, try to go through that, before threatening to take the complaint to the state DOI. If you do mention the DOI, the insurance company should snap to it and at least review your grievance!
If the formulary change was from one plan year to the next I would say it is probably your employer group's responsibility to notify you of the change. It is very common for formularies to change from one plan year to the next for cost-saving purposes. I have also seen formularies change on the Medicare Part D plans, but it is also normally from plan year to plan year. Changes during the plan year seem odd to me, especially for a drug like Xyrem that is probably taken by so few people that the least they could have done was send a letter to everyone who had a Xyrem prescription filled in the past 6 months!!
Hope this helps.
Excellent advice from Kimberly. I agree with her suggestions. The only addition I would suggest would be to request a "formulary exception" This is very similiar to an appeal or grievance but in some insurance companies if the formulary exception is requested, it will go to a difference department. Typically one staffed with medical professionals. A formulary exception allows the insurance company to give you what you need and still keep their current poicies regarding the drug.
Hope this helps!
#4
daveislate
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Posted 01 May 2008 - 08:37 AM
QUOTE (Kimberly @ May 1 2008, 03:24 AM) <{POST_SNAPBACK}>
Hi Heather,
Call the customer service number on the back of your pharmacy insurance (or medical insurance) card, and ask them what the procedure is to file a grievance.
The words "appeals" and "grievances" are taken very seriously by health insurance companies; as most have to abide by state law with regard to responding to formal complaints from members.
Another option would be to contact your state's Department of Insurance to file a complaint.
I would probably contact the insurance customer service first, ask for the grievance procedure, try to go through that, before threatening to take the complaint to the state DOI. If you do mention the DOI, the insurance company should snap to it and at least review your grievance!
If the formulary change was from one plan year to the next I would say it is probably your employer group's responsibility to notify you of the change. It is very common for formularies to change from one plan year to the next for cost-saving purposes. I have also seen formularies change on the Medicare Part D plans, but it is also normally from plan year to plan year. Changes during the plan year seem odd to me, especially for a drug like Xyrem that is probably taken by so few people that the least they could have done was send a letter to everyone who had a Xyrem prescription filled in the past 6 months!!
Hope this helps.
Call the customer service number on the back of your pharmacy insurance (or medical insurance) card, and ask them what the procedure is to file a grievance.
The words "appeals" and "grievances" are taken very seriously by health insurance companies; as most have to abide by state law with regard to responding to formal complaints from members.
Another option would be to contact your state's Department of Insurance to file a complaint.
I would probably contact the insurance customer service first, ask for the grievance procedure, try to go through that, before threatening to take the complaint to the state DOI. If you do mention the DOI, the insurance company should snap to it and at least review your grievance!
If the formulary change was from one plan year to the next I would say it is probably your employer group's responsibility to notify you of the change. It is very common for formularies to change from one plan year to the next for cost-saving purposes. I have also seen formularies change on the Medicare Part D plans, but it is also normally from plan year to plan year. Changes during the plan year seem odd to me, especially for a drug like Xyrem that is probably taken by so few people that the least they could have done was send a letter to everyone who had a Xyrem prescription filled in the past 6 months!!
Hope this helps.
Thanks for the advice, Kimberly! I did call Customer Service first, and they mailed me a very generic complaint form... Right now, I'm honestly struggling to find the right words for that complaint form... Lest I remind you, I have a penchant for profanity when I am especially upset.
Obviously, a complaint form full of that won't get me very far... I'm trying to find more appropriate & professional ways to express my unhappiness with their decision. You make a very good point about changes during the plan year, too... I am honestly very suspicious of the timing of their reclassification because so few people take Xyrem, and the change came one month after I started it... I know that I am my doctor's first & only patient taking Xyrem, and my insurance company is a relatively small one, so I would not be surprised if I was also their first member to take Xyrem too.
Again, thanks for the advice! I really do appreciate it! I'll let you know how it pans out.
#5
daveislate
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Posted 01 May 2008 - 08:40 AM
QUOTE (TJStarnes @ May 1 2008, 01:15 PM) <{POST_SNAPBACK}>
Excellent advice from Kimberly. I agree with her suggestions. The only addition I would suggest would be to request a "formulary exception" This is very similiar to an appeal or grievance but in some insurance companies if the formulary exception is requested, it will go to a difference department. Typically one staffed with medical professionals. A formulary exception allows the insurance company to give you what you need and still keep their current poicies regarding the drug.
Hope this helps!
Hope this helps!
Thanks! I will definitely keep that suggestion in mind also!
#6
TJStarnes
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Posted 02 May 2008 - 08:58 AM
QUOTE (daveislate @ May 1 2008, 09:40 AM) <{POST_SNAPBACK}>
Thanks! I will definitely keep that suggestion in mind also!
You're welcome. Maybe you can give me some advice too... My doctor wants me to consider Xyrem because other medications are pretty much max'd out and still have problems. I am just concerned about what this medication will do, I think because I know what's in it. I have children, will I be able to respond to them in an emergency or are you so out of it that you won't know they are there. Will I feel "drugged" in the morning?? What has your experience been with it?
