When Plans Go Wrong – When You Can’t Get The Medicine That Works

(To view the case of the original post, go to Case 1 under Cases To Consider on the home page.)

Though Susan said she couldn’t get the medicine that her doctor prescribed for her which worked in the hospital, that isn’t quite correct.  The reality was her health care insurer wouldn’t pay for that medicine.  She could have gotten it if she paid for it herself but did not want to spend the money.  That doesn’t sound fair.  After all it helped her feel better.  Why wouldn’t they pay for it?  The answer is simple, it is an over the counter (OTC) medication available without a prescription and health care insurance policies don’t usually cover OTC medications even if your doctor writes a prescription for them.

So what are Susan’s options.  She could just pay for the medicine herself. This medication is relatively inexpensive, costing under $6.00 for a 16 day supply of the generic, meclizine, at one of the national retail pharmacy chains.  A brand is slightly more, still under $9.00 when I checked.  In view of how bad she was feeling without it, buying it now seems to be the most logical choice. 

She could also appeal her health insurer’s decision.  To do that she would call the Member Services number on the back of her health insurance card.  Unless they agree to handle this as an expedited appeal, she may wait weeks for a decision.  State regulations dictate how rapidly they must respond to both regular and expedited appeals.  She could appeal it before or after she has purchased the drug, too.  In my experience, under these circumstances the insurer would probably not agree to pay for the drug even with an appeal, but she could try.  Her health care insurance policy is a contract that defines what is a covered benefit and what is not.  For consistency and fairness to everyone they insure, they must adhere to those definitions unless there are extenuating circumstances.

So, given how bad she feels without the medicine, I would urge her to buy the medication and submit an appeal to her insurer.

I’ll talk about how to deal with one of the other issues with her discharge plan that went wrong on my next post.

For Your Health – Dr. Bob