In my last post I talked about the ER visit that we did due to fever and noise in Caden’s left lung. That visit ultimately led to a follow up with a pulmonologist last Thursday October 8th. The pediatrician was concerned with this lingering fluid on Caden’s lung that appears to have never cleared up since the hospitalization for pneumonia caused by H1N1 flu back in August. The pulmonologist agreed that the fluid was lingering and decided to treat Caden with a drug called Pulmozyme. The doctor warned us that the drug was normally used for cystic fibrosis patients and would likely need prior authorization with insurance. I did not think much about having to jump through hoops to get a medication approved that was bring prescribed outside the normal use. We went through this with synagis shots for RSV prevention a couple of years ago because Caden did not fit exactly in the criteria that would qualify him for the shots.
This time things have become a little more complicated. We were told on Monday that the Pulmozyme for Caden had been denied. We were encouraged to appeal the denial for the authorization and I immediately wrote a letter to CAREMARK (the Blue Cross Blue Shield pharmacy arm) and faxed it in within the hour. Since we had not heard anything back today…and CVS was still getting a denial when trying to run the prescription, I called CAREMARK this afternoon. The man who answered was very nice and said that he could not verify that my faxed letter was received for another couple of days. He said it takes 3-5 days for an appeal letter to post in the system.He suggested that I simply pay for the medicine out of pocket and work on the reimbursement later if approved. I told him that the thought had crossed my mind but I did not have $1500 on hand for this medicine. I told him that if I and my employer stopped paying $1,100 per month for health insurance premiums then I might be able to afford to buy the medicine and since I was paying these premiums I would like to actually be able to get a benefit approved when a doctor determined a medication was needed to treat a serious medical condition. I asked if there was a supervisor I could talk to and he said that I had done all I could do and suggested that I call back on Thursday to see if the letter made it though.
Caden being the complex little guy that he is happens to have his own personal case manager with BCBS. She is the one who told us to appeal the denial on Monday. After my talk with CAREMARK I called her today and she poked around a little. What she found is that my letter had made it though and that CAREMARK had sent the medical records and my appeal letter out to a medical consultant for review. She said that she was told that this review of our appeal could take up to 30 days. She said the only alternatives we have to buying the medicine out of pocket or simply waiting on the review are (1) to get the doctor to admit Caden to the hospital or (2) to get the doctor to administer this medication in the doctor’s office or outpatient clinic. For some weird reason the insurance will pay without question if the same doctor who prescribed this medication gives it during a hospitalization. A medication given by the same doctor while a patient is hospitalized does not get the same level of scrutiny with the insurance company as when the medication is prescribed for home application. We have not had a conversation with the doctor yet to see if she wants Caden to have the medication bad enough to admit him in order to administer the drug.
In the meantime we are staying in the Marriott Renaissance in Asheville, NC for a couple of night thanks to my abundance of hotel points from my work travel in recent years. We will be apple pick’n and a look’n at the leaves. Our Big Boy Riley will be seven years old on Sunday and this trip is a birthday present. Tomorrow we are going to try to find the spot shown below on the Blue Ridge parkway again. This picture was taken 6 years ago this month.
