One of the big arguments against socialized medicine is that it puts the government between you and your doctor. I find that puzzling because insurance companies already are there. And an insurance company is a for profit entity that 100% does not want to pay for stuff your doctor orders. Every visit, procedure, or medication reduces their profits after all.
We’ve experienced many denials by our insurance company dealing with Ani’s health. Apparently figuring out what is wrong with her and treating her wasn’t actually medically necessary. Or so you would think if you just listened to them and how often they overrode her doctors.
My doctor had to make a huge case for me getting the pneumonia shot “too young.” Eventually, with lots of evidence provided that I’d had bronchitis and/or pneumonia at least once per winter AND wasn’t immune to most strains included in the shot, the insurance approved of me getting the shot. Considering I didn’t get any respiratory infections this season for the first time in years, I’d say my doctor was exactly right even though the insurance company didn’t agree at first.
Well now we’ve hit yet another time the insurance company is getting between my daughter and her doctor. She has been on Lyrica for four years. In August, the insurance company changed from covering the brand name to the generic. It was a little annoying since we were paying $4/month for the name brand thanks to a co-pay card and have to pay $60/month for the generic. But whatever.
Well, it turns out the generic doesn’t work as well for her. She’s feeling the electrical impulses coming from her spine like she did pre-Lyrica. She’s in a whole lot of pain like she was pre-Lyrica. She’s constantly in a flare like she was pre-Lyrica. So the doctor ordered brand name only for her.
We went to pick it up and it’s $795 a month. The insurance company said we can’t appeal since it’s not a denial. They just aren’t covering it. They said she is welcome to keep taking the generic (which doesn’t work) or switch to something else, but unless we want to pay almost $800 a month Lyrica will not be what she takes. So she called her doctor and is leaving it up to him what to do next. Hopefully the insurance company won’t have a problem with whatever that is, too.