Tuesday, October 11, 2011

Insurance company calls: Where's the survival guide?

Several weeks ago, I tried our new insurance company's prescription by mail service. I've always found ordering Max's anti-seizure meds in bulk to be a better deal than getting indie bottles from our local pharmacy. Besides, anytime I can have anything delivered, I am all for it. Like, if we ever decide to have that third kid, I am getting him delivered to our home.

The other day, I got a cryptic letter in the mail that said to contact the mail order company's Member Services Department. I call. The rep looks up the notes in the file and says that the pharmaceutical company does not have the medicine, Trileptal, available. That makes no sense, as this is a major medication, one used by more than one child named Max. Ten minutes later, she decides to get a pharmacist on the line. This is where the fun really starts.

I tell the pharmacist that I am not clear what is going on as surely, he would have checked whether it might be possible to get the generic form of the brand.

"There is no generic form of the medication," he says.

I am not convinced—both because Max's neurologist and I have talked about generic vs. brand and also, because as I'm on the phone with him, I do a Google search and find out that the medication went off patent two years ago and became available as generic.

I say, "I believe there is a generic kind of this medication."

He says, "No, there is not."

This is the opposite of helpful; even if there is no generic, what am I supposed to do? When might the medication become available?

I ask what the next steps are. The pharmacist says that I need to tell the rep how I would like to proceed. I say that I have no idea what he means. "The bottom line is, my son needs his medication. The risk for seizures isn't just going to go away."

The pharmacist repeats, "You need to tell the rep on the line how you would like to proceed." I say, "How I would like to proceed is, my son gets his medication!" And he says "You need to tell the rep how you would like to proceed." By this point, I am wondering if he is actually a pre-pre-recorded voice and whether soon there will be a "BEEP!" that sounds at the end of his sentences.

At last, the silent rep speaks up. "I have no idea what you want the customer to tell me," she says to the pharmacist.


The call takes twenty minutes. Toward the end of it, by which point I am anxiously bending and re-bending a large paper clip, I ask the rep why they hadn't called me sooner. If we were going to have an inane conversation, the sooner, the better!*

(*I did not say that.)

"We tried your phone number a few times, then sent a letter," she says.

"I didn't get any voicemails—what number do you have?" I ask.

She reads a number that is a) the wrong area code and b) the wrong number.

She takes down the right number.

[Hang up, rip hair out.]
So today, I have to order the medication from the local pharmacy. Perhaps I can pick up some sedatives for the next time I have to call the prescription-by-mail "people."

At times like this, I wish I had a fairy insurance godmother. I used to. Months ago, I was given a trial membership to a service called Off Your Desk, a health claims company that handled insurance claims for customers. It was quite the pleasure to mail off bills to a rep, who followed up on claims/calls and got us some money back. That company was sold to MedClaims Liason. The fees are hefty, but may be worth it to people who have serious medical expenses or who have a low level of time, tolerance, and patience for dealing with medical claims and/or maddening insurance company staffers.

For now, I will be forced to waste precious moments of my life dealing with insurance company crapola.

I suspect you, too, have wasted more than a few precious minutes of your own life on similar calls?




  1. I'm in canada!! I have to say the only time I have spent time on the phone with our insurance company was last week when i phoned out of interest to see if a breast pump would be covered since baby is going to be taken straight to the pediatric hospital after birth. Answer: with a drs note that it's medically required, yes. Up to $200. I didn't even need to talk to them when I claimed death benefits for a family member. I just provided the death certificate with my claim.

    With a child about to be born that needs a liver transplant, I've read some horror studies about dealing with insurance companies. I don't anticipate problems in that regard.

  2. I was recently told by our pharmacy that they stopped making/carrying Trileptal in the generic form. Maybe that is the issue? We are looking into other pharmacies to make sure, but the pharmacist told me that we would probably not be able to find anyone carrying the generic anymore.

  3. I'm sorry you had such difficulty! We have been very fortunate with our mail order pharmacy for my husband's medication, but don't get my children's through them because of their secondary insurance with the state medical card and have to go to the pharmacy multiple times a month! Hopefully things will improve!

    Does your insurance have case management for people who have serious health conditions? We have someone that we can call through our insurance specifically to get help with the battles. Something to look into.

  4. I feel your pain. We have been using Prevacid for the past year and then one day the pharmacist tells me that can't get it anymore and to call the doctor for another medication. Uh hello- this was the 5th medication we tried for my son's reflux so its not really that easy. We did find out that a lot of medications are on back order or generics being discontinued because the FDA has cracked down on pharmaceuticals facilities in South America due to poor practices.

    We were able to get the prescription by going to a big box pharmacy but life would be a lot easier going to my friendly neighborhood pharmacist.

  5. Follow the money. Odds are some Big Pharma company making the med bought up the company making the generic and effectively re-created a monopoly. I hate these catch-22s. I could regale you with nightmare stories but it would depress you! You just have to be one of those B-words and not take no.

    Ironically we got fewer hassles in the safety net programs when I was poor and unemployed than in my current policy I get on the job.

  6. The generic is still sold through Costco online. At 300MG/100 tablets, it's $330 less than name-brand.

    If the pharmacy partner refuses to dispense a drug on the formulary, ask the insurance company to give you a special waiver to buy in bulk via the local pharmacy. The waiver costs the insurance company no more than the mail-order; you just pay several co-pays at once. They just drove a customer to buy the name-brand version from the costliest souce. This makes no sense.

    I don't believe there are many different options for pediatric seizures; I think this one is considered to have lowest overall side effects. Still, it could be worth asking your doctor about other options, even something as simple as a higher dose/pill-splitting, to get around the refill issue. Having more options, or confirming that you're on the right road, never hurts.

    Good luck.

  7. My pharmacy (and a second one I called) told me that the generic of Trileptal is unavailable at the moment (backordered or something). It has been backordered for months. I have had to pay more for the name brand even though the generic isn't an option. My son takes the liquid. Let me know if you find a place with the generic liquid!!!

  8. Just wanted to add that I shouldn't have assumed Max takes the pill form. Also, when I said buying name-brand from the pharmacy made no sense, I just meant *to the insurance company*, because that costs *them* the most. There can be lots of good reasons to stick with name-brand-- such as no generic being available in liquid. I'm sorry to hear it.

  9. My Mom was put on the generic for Trileptal two months ago. She was switched to Trileptal because its supposed to have less side effects, but was considerably more costly. So six weeks ago it was available, and the pharmacist should have explained what is going on.

    Terrible side effects of both.

  10. I feel for you!! I work in Billing for an ophthalmology practice and speaking to insurance companies regarding claims is MADDENING. We have a lot of special moments after our phone calls. You sound like you have an excellent handle on how to go about claims tho-I think I remember you saying someone had shown you how to look up CPT codes and related diagnoses to make sure you can get a claim to pay out. It is pulling teeth sometimes but isn't it such a little victory when you get one right?!

  11. im anxious just reading that. oh dear

  12. Cindy, it sounds like you are going to have a lot on your hands (I will come visit after this); I am glad that, at the very least, you won't have insurance worries to contend with.

    The upshot of my story: My local pharmacy got the medication (brand of Trileptal) ordered, no problem, and it'll be here tomorrow. We can only use the liquid. If I hear of any changes with the generic version, I will let you guys know.

    Anon, thank you for the info. We do like this medication because it hasn't had noticeable side effects. Yes, we would have to consider something else should they completely stop making it, but I am not sure why they would. Then again, what do I know about the wild and crazy pharmaceutical world.

    Felicia: THAT is irony.

    And yes, Eryn Marie, "pulling teeth" is THE perfect description.

  13. This cracked me up. Sometimes it seems like the ultimate irony that I - DEAF MAMA - have to CALL for everything that my daughter with Down syndrome needs. It's like a root canal without the novocaine. How do you spell novocaine anyway?

  14. Like other posters, I have also been told by our pharmacy that the generic for the liquid form of Trileptal is no longer being made (for now). Prior to this declaration, I had several conversations with them like the one you had with your insurance company... the generic was backordered with supply problems, and I was frustrated because it's not like we can just sit around without giving my daughter seizure medication while they figure it out. On the bright side, I just picked up the brand name of it, and it was the smoothest transaction ever (except that they won't divide bottles, and my daughter needs more than one bottle for a 30- day supply, and insurance bills two co-pays for even a 31-day supply, so we pay the brand co-pay for less than a 30-day supply... Sigh...).

  15. How unbelievably frustrating! Been there myself with mail order meds and doctor/hospital bills. We too used MCL (MedClaims Liaison) https://www.medclaimsliaison.com/ and like you were so truly grateful to be able to just mail off the bills and have someone else file the appeals, do all of the follow up phone calls, wait on hold and file all of the claims on our behalf. I too was a bit leery about the membership fee but with one single issue they totally recouped that fee for us. We were given a bill for several thousand dollars which we would have begrudgingly paid over time but they picked up that there was an error and filed all of the paperwork and did all of the follow up calls etc. for us. We ended up having to pay several hundred dollars instead of several thousand! They not only saved us a LOT of money but an absolute ton of time, frustration and angst. I hope that by the time you read this that the medication issues have been resolved and have been delivered to your doorstep! When caring for a special needs family member the last thing you need is another reason to lose sleep or give you more anxiety. Hang in there and good luck!

  16. doozee, yes, that is definite irony!

    Andrea, glad things went smoothly for you. More irony: Today, our local pharmacy couldn't get the meds because the mail delivery company is in the system as having delivered them. More phone calls! Yipppeeee!

    Wow, Maureen, that is some rave. Do you, by any chance, get paid by MedClaims to spread the good word?

  17. Oh boy here I go even though we have good insurance they can be difficult I have 14 year old twin girls one who has Mosiac Turners Syndrome and was on Nutropin injections for 8 years and the other who has a hearing loss.Both of these things haved caused issues with insurance company espesially after the Nutropin provider set up a frustrating order system that had broken lines with insurance and when my other daughters hearing aid was not covered by insurance as she is not over 65? still dont get that one it was straingned out and when CVS and the insurance would not fill prescritions for pinkeye for both of them because of same birthdates.


Thanks for sharing!

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