Dealing With Insurance Companies
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How To Get Around Insurance Company Restrictions
by Matt Matlock
As Cluster Headache suffers
many of us depend on triptans as a lifeline to sanity. Imitrex
(sumatriptan), Frova (frovatriptan), Zomig (zolmitriptan), Amerge (naratriptan),
Axert (almotriptan), and Maxalt (rizatriptan). As abortives, triptans have
saved us from many hours of excruciating pain. One fact about Triptans is
that they are expensive. Another fact is that insurance companies do not
like them and limit the quantity that they will pay for.
The company that I worked for had changed insurance companies not too long
ago and I had gone from a company that I had to fight just to get them to
approve a prescription for 5 vials every 30 days to a company that would
allow 1 vial every 30 days. I was furious to say the least. At the time I
was having five attacks a day. Each attack lasts up to 90 minutes. My
cycles generally last for 3 months. That is 675 hours each cycle of some
pretty serious pain, and I am one of the lucky ones.
Something was not right. I could not understand how insurance companies
could deny us a treatment that our doctors prescribed to us to relieve us
of this horror called clusters, even for just awhile. I began researching
the subject and came across a couple of articles written by Teri Roberts
on exactly the same subject. She described her crusade against the
insurance companies and outlined her arguments the insurance companies “right”
to deny patients the relief they deserved.
With a few changes and adaptation to my own plight I argued with the
insurance companies using Teri’s logic. I won the argument and was
allowed the needed amount of drugs I needed. I am now allowed 5 vials
every 10 days and that covers my needs, I am no longer forced to sufferer
needlessly. I believe the same could happen for most suffers if they
remember that they are their own best advocates and stand up to the
insurance companies. Following are some things to remember when talking to
your insurance companies. I plagiarized Teri on some of this, Thanks Teri!
1. Record your conversation with them. Be upfront with them that they are
being recorded. Be sure to have your policy in front of you, and know it.
They may quote clauses in it that do not exist. If they quote from it let
them know it is in front of you and ask exactly where they are quoting
from.
2. Ask for names when talking to representatives, both first and last. The
insurance companies will make statements that turn out not true to deny
you your triptans. In my opinion this is their Achilles’ heel. In my
experience they do not want to give their full names out, if they don’t
give you their name ask for their supervisor, or in my case their
supervisor’s, supervisor’s, supervisor.
3. One of the first statements that they will make is that FDA regulations
prohibit the amount of Triptans insurance companies are allowed to cover.
Teri had talked to Ms. Brenda Stodart at the FDA who confirmed that the
FDA has no jurisdiction over any insurance company. The FDA regulates the
pharmaceutical industry, not the insurance industry, and no FDA
regulations would have any effect on payment for prescription medications.
4. Another untrue statement is that FDA restricts the amount of Triptans that you can use in a 24-hour period. The only limitation is from the manufacture is the maximum dosage in a 24-hour period. The FDA has no jurisdiction to do so, and they don’t.
5. They may also tell you that it’s in the FDA legend.
The FDA Legend is the FDA’s approved prescribing recommendations as
outlined on the package insert. This is set by the manufacturer and is
only the suggested limitation for a 24-hour period. This has nothing to do
with you insurance company. When they quote from the FDA Legend they are
making the implication that limiting Triptans it is a federal regulation.
This is not the case; this is where asking for the representative’s name
is important. Would you want to be on the record quoting non existing
federal regulations to deny someone a lawfully prescribed medication?
6. Yet another untrue statement they may use is that Triptans are
addictive. The 5-HT 1B/1D agonists, as a class, have not been associated
with drug abuse, at least according to the FDA Legend. Use their own
recourses against them. Ask for any reference material that they have
stating that it is, including the name and the credentials of the person
that says they are addictive.
7. Have your policy/plan booklet in front of you when you call. If they
tell you the limits are in your policy, tell them you have it in front of
you, and ask them exactly where it is.
8. By changing your attending physician's orders as
expressed in the prescription he/she wrote, they are practicing medicine
without a license. When they tell you they have a review panel that
includes a physician, the physician on their panel is committing
malpractice since he's changing your attending physician's orders as
expressed in the prescription when he's never examined you. Ask for that
physicians name and credentials, and request to speak to him directly.
9. Another common mistake made by the insurance companies is that they are
treating you as a migraineur. You may have to point out several times that
you do not have migraines but cluster headaches. Treating them as one and
the same is a medical mistake.
10. Remember that you are your own best advocate. Be assertive yet polite.
When given an untrue statement, tell them that it is untrue and ask from
whom they are quoting and ask to speak to that person directly. Ask them
if they are sure they want to be on the record quoting that statement.
Remind them of the cost of an ER visit, mention to them that you would
have no choice but to go to the ER for the attacks.
Some links for further reading, and again Thank you Teri.
http://headaches.about.com/cs/advocacy/a/trip_limits.htm
http://headaches.about.com/library/weekly/aa-bc-trip-limits-a.ht
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http://headaches.about.com/library/weekly/aa-bc-noreply-a.htm
Disclaimer: This article, from the June 2007 OUCH Newsletter, is based upon the personal experiences and research of Mr. Matlock and is provided as a service to cluster headache sufferers. The views and/or opinions expressed in this article do not necessarily reflect the views of OUCH.