You really have to hear this! Another insurance company rant that will blow you away.

I will apologize in advance as this will be a venting session.

Right before the New Year I called in Bryce's monthly prescriptions as I have done every month for years. Once I went to the pharmacy to pick them up I was told that his Prevacid would need a PA (Prior Authorization) in order to be able to get the refill. As a side note this is for his GERD (gastroesphageal reflux). Reflux for Bryce is not like indigestion or heartburn for me. It can cause many other gastroenterologic complications and even hospitalization.

I was frustrated but it wasn't a huge deal because we still had a few tablets left and I would call the doctor to get it straightened out (which I did the following day). The doctor called the pharmacy and faxed in the required paperwork to my Insurance company. I go to the pharmacy yet again and they still do not have what they need to fill the order. I leave much more frustrated because at this point we have no more Prevacid for Bryce. So on the third day I call the insurance company again and ask for a status and they inform me they have not received the information from my doctor (the doctor that informed me the day before that they sent everything to them via fax). Hope you are still following...

So (since I do work full time) I decided to try back a little later. The doctor's office phoned me before I had a chance to call them back. The nurse on the phone said she had been rounds with the agent she spoke to with my insurance company. Basically - the medical director decided they would like for Bryce to "try a new prescription." They also suggested that he trial Nexium. This is where I completely lose my mind. As most people know Bryce is a very complex little boy. One thing is for sure - we DO NOT mess with something that is working for him. Years ago Bryce's GERD was out of control and we had to trial many things before we found that Prevacid is what he needed. He cannot take Prevacid that is on the shelf at your local Walgreens because he cannot safely swallow the capsule. He is prescribed a salutab that dissolves in his mouth and it has worked very effectively. In fact, he did go through a small spell a few months back which required us to increase this dosage. After a day or two - it was back under control. So you can imagine my frustration with the denial of this refill.

I (of course) call the insurance company and speak to a supervisor. Apparently starting this year they have decided that this prescription would need a Prior Authorization before being covered. They also denied this PA even though Bryce has been on this for years. I asked and they confirmed that we were not notified in any way. Apparently they do not have to inform you of this change. I went on to explain Bryce's history - I explained that he had already started tapering off on eating and he had spent the past night in bed with me and Matt refluxing all night long. The supervisor informed me that the only thing I could do was to file and emergency appeal that would take 72 hours to review. Keep in mind Bryce is already 5 doses behind.

I have many issues with this.
My first issue is that he is a medically complex child and that can be seen by opening his file. The insurance companies DO NOT HAVE the right to determine if my son needs a specific medication or not. That determination is up to the medical professionals that treat him daily.
My second issue is that if such a policy change occurs regarding a specific medication, then that company should be required to inform any patient that is currently taking this medication. There should be at least a 30 day notice of the change in a situation such as this. This allows the parent or guardian to take the necessary steps BEFORE the medication needs to be refilled. This would eliminate the time the patient must go without that medication. Where is the right of the patient?

My third issue is that my son’s PA was denied and then we have to go through an appeal process. The emergency appeal would take 72 hours which is just added time where he is not able to receive his medication. Since there was no notification sent to the patient/guardian then there should be policy in place to allow a remaining refill so that the patient does not go through a prolonged period without the medication that they need daily.

Ultimately our absolutely awesome Dr. Chris Bolling (Pediatric Associates) did write an emergency appeal on behalf of Bryce. The letter he wrote was amazing. He did state that "abrupt discontinuation of this singularly effective regimen is medially reckless." Have I mentioned that this man has always fought for Bryce as much as I have. We continue to await the decision of the insurance company. I did go to the pharmacy to check on privately paying for his meds and it would cost me over $600.00. I certainly cannot afford that so I have purchased 6 pills that cost over $50 to get us through a couple of day. He takes two pills daily. I have also written an official complaints and submitted them - but there has to be change! I am absolutely blown away with this and as a parent your hands are tied but I promise to make several calls a day and be as nagging as possible until I get this approved. I will also see if there are any possible steps I can take to ensure that they change their procedures.