Mad Tears: Fighting Insurance for My Health

Today is the first day that I have wanted to cry since I began fighting Blue Cross for coverage of the newly prescribed medication for my autoimmune disease.  Not because of pain.  I’ve done that before.  Just out of frustration. 


I didn’t cry.  I was at work and there’s no crying in lawyering.  Especially not if you’re a girl. 


This whole health insurance mess is ludicrous—like something out of a Dilbert cartoon.  It is funny in a postmodern, Quinton Tarantino, brains on the back seat sort of way.  This is dark stuff.


The story is simple. I have a disease which, according to my insurance company’s published materials, qualifies me to use a very expensive drug called Humira.  My doctor prescribed this drug after another, exponentially less expensive, drug stopped working.  Humira costs about $2600.00 per shot.  As one of my friends with MS likes to say, “we’re talking dolla bills, people.”  My insurance company is performing contortionist-like feats to avoid paying for my Humira. 


Because of this no-pay yoga, I went three weeks without any medication.  I got sick.  The kind of sick where my alarm went off and I was so exhausted from the inflammation run amuck in my body that I went back to sleep with my children jumping on me.  Literally.  Kids jumping were on my head and I was still sleeping. They ran screaming through the house.  Asleep.  That tired.  And then when I did get up, I’d sneak out to my minivan to catch naps, oh, whenever I could. 


My joints hurt a little.  Like they might if you stepped out in front of—

the space shuttle.  Because autoimmune arthritis is systemic and my form of it means that I had tenderness and swelling in my shoulders, elbows, wrists, fingers, hips, back, knees and ankles, I was feeling like I’d been hit by a rocket.  Maybe more like on re-entry than take off. 


All the while I kept getting these pleasant voicemail messages on my cell phone.  Automated, of course.  “We’re calling from Curascript.  We just want to let you know that we’ve received your referral for your prescription and we’re processing it.  We just need a few more items.  You don’t need to do anything.”  And so I thought I’d get a nice package full of lovely Humira in the mail just any day.  That is, until I called to see if, even though I didn’t need to do anything, if I could do anything to speed the process up.  Because I was still working, and raising two kids, and I needed my meds.


I won’t bore you with the seven different phone calls it took for me to get someone on the phone with useful information about why I did not have a needle full of unicorn tears, or whatever Humira is made from that makes it cost $2600.00 per injection.  Suffice it to say that it took me swinging around the old J.D. (mentioning on the phone that I was a lawyer), and mentioning that I didn’t have any medication, and mentioning that I was getting sicker by the day to get an actual person on the Death Star, I mean Pre-Authorization Department in the insurance company on the phone.  This person told me that my doctor had sent them a form containing the necessary information about my health and my need for Humira, but it was not the Proper Form, so they could not process my claim.  They also said BlueCross had attempted to notify my doctor and tell him so.


So I called my doctor, who is a full professor at a public university and who also treats patients.  He doesn’t have much time to fool with insurance companies.  You know how this goes.  My doc’s office hadn’t gotten anything from BlueCross until about three minutes before I called them letting them know about the need for the Proper Form.  The doctor’s office was so very apologetic and had me come in for an injection of the magic elixir, paid for by the drug company.  Hey kid, the first one’s free.


Basking in the glow of my first Humira injection and reading over the patient porn that tells me how good I’m going to feel once it begins to work, I begin to think everything will be o.k.  I have forgotten the rule all lawyers know. Because I am standing there when my doctor fills out the Proper Form and faxes it in to BlueCross and it says that I have the Necessary Disease to qualify for the Humira I mistakenly think all has been fixed and I am on the road to recovery and peace.


Until today—a week ahead of my next injection—when I called Curascript to ask when I should expect my parcel of medicated goodness.  That is when I was reminded of the first rule of lawyering.  That is this:  It can never really be fixed with a phone call (or even a few phone calls).  Not really.


Lawyers learn this early in their practices when clients come in and tell starry-eyed young things that their big companies are afraid of bad press and will crumble if only said young lawyer will just send a threatening letter or make a phone call.  Not.  True.  If there are any young lawyers out there reading this…don’t buy it.


There is another hitch.  No wait, it’s the same hitch.  BlueCross needs another Proper Form to verify that I have the Necessary Disease.  They have sent me fax confirming their need for it.  I have yet again called my doctor’s office asking them to send said form.  The ridiculousness of this dance is apparent.  The fax to me says I must have Psoriatic Arthritis—which I do—to qualify to take Humira.  It says I must have failed at least one other drug treatment—which I have.  The information currently in the insurance company’s hands says as much.  But they need More Forms. 


And so I am left wondering, as I wield my J.D. around: What do people do who do not have my knowledge, tenacity, or economic power?  I mean at least I have insurance (in theory).  I know my way over to the Attorney General’s office.  I am empowered.  What do grandmas with RA do?  What about the uninsured with MS who are going blind?


Yes, this is absurd in the extreme.  But what about those for whom the result is simply that they are told “no” and they take it?


For now, I’m feeling better after the one free Humira shot I got from the doctor and from the steroids I’m taking to control the inflammation until I get “up to dose.”  We won’t know if I fully respond for weeks.  And I may need to try other biologic medications like Enbrel or Remicade.  Some patients respond to one drug and not others.  Am I going to have to do this each time?  I truly don’t have that kind of time.  Either the time to be sick or the time to fight with the insurance company.


And yet I don’t have the time not to.




11 Responses to Mad Tears: Fighting Insurance for My Health
  1. Becoming SuperMommy
    June 26, 2012 | 9:50 pm

    Thank God we don’t have socialized healthcare in this country.

    Then there would be no incentive for companies to invent the unicorn tear drug.’


    …sorry, I can’t tell you how familiar all this is to me. Getting my husband his oral chemotherapy was pretty much just like this. Every month.

    The health care system in this country is utterly screwed.

  2. Amanda O.
    June 27, 2012 | 1:05 am

    Wow…the U.S. healthcare system continues to baffle me. We have insurance – supposedly for the “insurance” that if anything happens to us, they would do everything they can to help. Right??? What a joke. I’m sorry you have to go through this and I truly hope it all works out.

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