Question:
I HATE the power of HMO's. What an arrogant bunch! My doctor prescribes a
specific medication. My pharmisist tries to fill this very specific
medication. Oh but the HMO, that we pay dearly for, says, NO!! It is not on
their formularity chart! Okay, so I think to myself, that it must be a cost
thing. I check with my pharmisist, nope, exactly the same price. So what's
the deal. The new medicine makes me sick and I know the old medicine that was
prescribed by a VERY qualified physician does not make me more sick, but helps.
I ask the doctor to intercede and he does. HMO says request denied!! Who the
hell are these people? What gives them the power to overide a doctor?
Health Partners my ASS!! Yeah, now I will pay the full price for the meds and
still have to pay these assholes their weekly premium until next year when I
can select another bunch of morons to help pay the bills. Insurance has never
changed from when gangsters sold it so your business would not "burn down"!
Answer:
You can appeal to the state, I believe. I don't know the exact
procedure. Check with your health plan. By law, they are required to
tell you how to file an appeal.
How ironic! I suppose that will be an easy process. It will be a, "call
this number" and they will say, "call that number" and back and forth we go.
I think I will tap the burglar on the shoulder and ask him what the phone
number to the police department is. I bet he would even call for me and
handle all the paper work too!
Every time I hear a story like this I think of "The Rainmaker" by John
Grishom. I didn't read the novel, but I saw the movie. If you
haven't seen it yet, I'm sure you'll enjoy it.
So what is the deal? Did the explain why they wouldn't cover a drug that
doesn't have a cost premium over their equivilent in the forumulary?
Is Health Partners the new name for Group Health? I had Group Health when I
was a U employee (it was the no-cost option), and I was never too impressed.
Long waits for a doctor, and the whole experience felt like a trip to drive
through.
On a related note, I got a telemarketing type call asking me to participate
in a "forum" on heathcare issues about a year and a half ago. We sat around
and discussed when it was OK for HMOs to refuse coverage (experimental
treatments, etc). They mentioned that all HMOs in Minnesota are non-profits
by law (and kept mentioning it..). It was kind of a telling experience when
I asked the moderator, "If all HMOs are non-profit, why don't they just
merge together? They would then dilute the risk pools, and conceivably
lower costs.", they told me that those kinds of questions "...weren't part
of the forum...".
The drugs on a formulary list are generally from certain drug companies with
which the HMO has a contract. This all has to do with money, not necessarily your
health. When we rely on our employers to provide insurance that pays for most of
our health care, guess who is in charge. We can get any level of care we wish...if
we are willing to pay for it. Of course you can get whatever your doctor
prescribes, but unless you are willing to fight the people "in charge", be prepared
to pay.
I am happy to see that people are starting to question the care received at
HMO's, the payoffs that doctors receive for not ordering tests and procedures, and
the for-profit status of some HMO's.
