Comment on when the insurance won't pay for the medicine you were prescribed

• KamikazeRusher@lemm.ee ⁨1⁩ ⁨year⁩ ago

  Let’s say you get diagnosed with a treatable autoimmune disorder. Treatment isn’t cheap, so usually someone who recently got diagnosed and referred to a specialist to perform care will find that their insurance denied approval for prescription of medications and supplies needed.

  The insurance companies will want the doctor to re-submit while providing documentation of the diagnosis (as proof) and an outline of the treatment plan. The insurance company can say “your plan states six months of injections but we will only approve for three.” At that point, the patient is stuck with a three-month plan because the cost of treatment is too much to pay out of pocket and the doctor won’t go forward with a six-month plan unless the patient pays in advance for the three months that wouldn’t be covered.

  Another example is rare disorders where the medication may cost hundreds of thousands of dollars. Insurance may decide the cost is too high and deny coverage for the prescription.

  Finally, there are instances where more common issues (such as diabetes) may have the insurance artificially limit how many doses of a drug they decide to cover. If a person has a special case (like needing to take twice the amount due to tolerance or it being based on the person’s weight), insurance may deny it because it exceeds what they believe the average person should need.

  All of these are examples where someone is stuck waiting for what is essentially life-saving medication just because insurance doesn’t want to pay out, or doesn’t care that you have a special scenario that requires some exceptions for it to work properly.

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  • cheese_greater@lemmy.world ⁨1⁩ ⁨year⁩ ago

    Of course, I definitely didnt mean to minimize the issue. It really is insane there’s all these ridicululous middlemen and compromises that add to whatever condition as a threat to people’s health

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    • KamikazeRusher@lemm.ee ⁨1⁩ ⁨year⁩ ago

      Nah I didn’t read your original comment as minimizing it, but rather saw it as someone who might not be from the USA. It sounded like genuine shock to how life-saving meds could just be flat-out denied for somebody.

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      • cheese_greater@lemmy.world ⁨1⁩ ⁨year⁩ ago

        Thats very insightful and correct, altho we don’t have universal coverage here either and I’ve done this process several times. There are people who try once and give up and I just want people to be aware of what parallel structures or processes might be available to help give that a second look

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  • Hyperreality@kbin.social ⁨1⁩ ⁨year⁩ ago

    Not American, but are you sure they're not just delaying it because they've calculated that some people will die or give up, which increases their profits?

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