Thank You for Waiting 2 Hours: The Dark Side of ACA

Late last year, around October or so, my endo, primary care, my wife’s primary care, OBGYN, and endo all sent us letters stating that they were no longer accepting our MarketPlace insurance plan. This led us to searching for something new. Instead of just choosing a plan, we asked what MarketPlace plans they accepted. There was only one common plan, Ambetter from Sunshine Health. Don’t sound familiar to you? That’s because it’s a Florida based insurance plan, meaning, it can only be used in the state of Florida. That poses an obvious issue, but more on that in a later post.

My wife and I had to plan our yearly checkups and needed to find a new PCP. After calling about 10 who were either not accepting new patients, or didn’t have any openings for new patients for a few months we finally settled on one. We decided that we would schedule back to back appointments so that way one could be with the kid and then we could switch. These appointments were staggered between 2:45 for the first and 3:15 for the second.

My wife checked in for the appointment at 2:40 and she also checked me in while I walked the kid around in the stroller with the hopes that she would take a nap. After my wife filled out her paperwork, she thought it would be a good idea to hand me mine outside so I could get a head start. This was now around 3:00 p.m. (15 minutes after my wife’s scheduled time.)

At 3:15, which was my scheduled appointment time, my wife had still not been sent back to see the doctor. At this point, I am become a bit irritated, as I continue to walk around outside in 80 degree weather.

3:30 – nothing.

3:45 – nothing.

4:00 – nothing.

4:15 – my wife finally gets sent back to get her vitals taken.

At this time, it’s now an hour and a half past her original appointment time and then she was sent to another room to wait after her vitals were taken.

Finally, at 4:30, 1 hour and 45 minutes after her appointment time, she sees the doctor. This is the same time now that I get my vitals checked, 1 hour and 15 minutes after my scheduled appointment time.

After all was said and done, both of our check ups, in an-office EKG (which came out fine for me), and a few lab scripts later, my wife and I left the parking lot 2 hours and 45 minutes after our initial scheduled appointment time.

To say this was a nightmare and a disaster and an example of some of the negative effects that ACA has caused is an understatement.

There are not many doctors that take MarketPlace plans, this just so happens to be one of them. Which means, all of the people who are on a MarketPlace plan have very few doctors to choose from which creates these enourmous backups.

What’s the longest that you have ever waited for an appointment?

Prior Authorization Needed for Test Strips

One of the many hoops to jump through when you have diabetes is the need for prior authorization.

Last year I had a lot of problems with my Florida Blue health insurance. I documented a lot of this on Twitter and some issues here on the site. I had so many issues with them as a company and then found out that 100% of my doctors and my wife’s healthcare team were going to stop accepting this MarketPlace plan that I had. So, I only had one choice, changes plans.

I switched to a new plan for a January 1 start date and so far everything had been going great. My premiums are cheap, my deductibles are not a bad cost and all three of the major insulins (Novolog, Humalog, and Apidra) are all covered as a Tier 1 drug and covered at a $75/90 day supply.

The prescription process was simple and easy. Everything was great…… until I needed test strips.

Prior Authorization Confusion

My doctor sent in a script for me to test 6 times a day. Problem is, the insurance will only cover 3 times a day. Not a big deal, I will have my doctor send in a prior authorization. Well, here is where it got interesting.

The mail order pharmacy told me that the prior authorization was needed and they provided me with their fax number. I sent that to my doctor and they sent it in right away. A few days later, I called the pharmacy and they said that the insurance company is still not covering the strips. They said that I had to send in for a prior authorization. I explained I did, but, it was sent to the mail order pharmacy and not to the insurance company. I then requested something to be sent to the insurance company. My doctor called me and said that the insurance company doesn’t have a prescription on file. And, they have no clue what the prior authorization is for.

They didn’t have anything on file because the prescription was sent to the mail order pharmacy. After a few back and forths, the insurance company had a 3-way call with my doctor and my mail order pharmacy to get everything straightened out. I still have to wait another day or 2 until it all processes and I can find out if or when I have an order shipping.

Then, to add to that, once it’s ready to ship, I have to provide a different shipping address, so let’s see how that is handled as well.

The short story of the long story is this. Prior authorizations suck. I know at the end of the day (or week or month), I will get what I need because my doctor’s office will ensure that I do, but having to jump through the hoops sucks. And the 4-5 hours total spent on the phone between the insurance, mail order pharmacy and doctor’s office is even worse. The fact that as a type 1, my insurance is only covering 3 tests a day does not make any sense at all.

I can understand 4 times a day, a test before every meal… breakfast, lunch, dinner, bedtime. But only three?

Not cool.

Do you have any tips, horror stories, success stories about prior authorizations? I’d love to hear them. Please share in a comment below or on Facebook.


Update (02/13/17 2:30 PM

I received a phone call from my doctor this morning stating that they received a confirmation letter from the insurance company that the prior authorization has been accepted. I then received a call from the mail order pharmacy shortly after and they stated that they did not see the update on the acceptance of the prior authorization. However, when they attempted to put the claim through, it accepted the larger amount of strips, 6 per day. Unfortunately, the cost came out to over $100 which is not what the price is supposed to be.

One day I will get these strips.

Back on Novolog After a Rough Summer Without It

The summer of 2016 is one that was something that I would love to forget when it comes to my diabetes. I was using a temporary insurance and this temporary insurance did not have any prescription, well it did, but if you call getting your insulin at 10% off retail costs coverage, than ok.

I was using Novolin R during this 90-120 day period. I was using this because it was affordable, at only $24-$27 per vial at Walmart. This “insulin” was affordable but it did not work. No matter what I tried, I could not get my blood sugars to act anything like they do when I’m using Novolog.

I would take 30 minutes before eating and still shoot high. I’d not know that I was going to eat soon, so I’d end up taking the insulin over 5-10 minutes before hand and my sugar levels would sky rocket. I would take a large amount of insulin to correct a high and it would do nothing, so I’d take more, and then 6 hours later, in the middle of the night, I’d drop down low and need to correct with middle of the night Skittles and OJ.

September 1 started my new insurance that allowed me to pay $50 for my 3 month supply of Novolog.

I had a feeling that my A1C was going to be pretty bad (and no, I don’t care about my A1C). I was right, it was the highest that it has been since I was diagnosed 12 years ago.

I have also lost about 15 pounds since I returned back from my summer trip, so I know that’s going to continue to help with my insulin usage. Which means better eating, more time at the gym, which both lead to lower glucose levels.

Prescription Refills Made Easy

I know, the title sounds like some sort of bad ad copy for a mail order prescription company, but that’s not what it is. I used to get my prescriptions for oral medications filled at Target, but once they switched to CVS Pharmacy, I got out of dodge as quick as possible. I’ve written several different times over 7 years about my disappointments with CVS.

I decided to switch my oral prescriptions over to Publix pharmacy. Publix is a local grocery store in Florida. It is actually one of the companies that ranks in top 20 businesses to work for in the  country. I switched because where I live, there is only a Walgreens and a Publix and Walgreens didn’t take my insurance, so Publix it was.

I loved how quick and easy it was to get my prescriptions there. There has never been a line to wait in, they call my doctor for any refills or updates needed, they deal with any insurance issues, they call me if there is an issue instead of waiting until I get there to pick it up, they text me when it’s ready, along with the exact price (my generics change every time so the costs vary depending on which generic they are using), and the staff is very friendly.

Because of this, I’ve actually decided to start getting my test strips and my insulin from them on a monthly basis as opposed to saving $20 and getting a 3 month supply. The mail order pharmacy that I had to deal with was always filled with insurance. If at anytime, I needed refills, or emergency orders, it would take “24-48 hours to process a new refill request, and then another 24-48 hours to ship out”, meaning that it would take a minimum of 2-3 days to get a new prescription or update to my insulin prescriptions shipped out.

I’ve now been using Publix for 3 months now and I absolutely love it.

It has been the easiest time in over 10 years of dealing with insurance and supply refills.

10 Hours on the Phone with Florida Blue and Marketplace

My wife and I have been covered under an insurance plan from her employer for a couple of years now. Since she is no longer working, we were able to still use the insurance, but in January, we were going to have to switch to COBRA and as we all know, it was going to be crazy expensive.

So, I decided that I was going to go out and get insurance for myself. Just to be able to say that felt so damn amazing. Thanks to the Affordable Care Act, I am able to go out and search for my own insurance and include my wife and daughter on that policy. The downside? I had never searched for health insurance before, so I was absolutely clueless where to start.
On December 15, because why wouldn’t I wait until the last day in order to get coverage starting January 1, I sat on the phone with Florida BCBS for nearly 3-4 hours trying to get an application in for a marketplace plan. I knew that I would be receiving a subsidy, so I didn’t want to get a plan directly through Florida Blue, but wanted a marketplace plan that was Florida Blue’s.

This took so long because I needed to have myself, my wife and my daughter all added into this application and added to the plan.

After several hours, I was done. I chose a plan, I knew how much my premium was going to be and everything was set. All I had to do was pay my premium before January 1 and I was good to go.
January 2 came and I had already paid my premium, so I called Florida Blue to find out what my member ID was because I had a doctor’s appointment on Monday, as well as my daughter. When I called, they couldn’t give me my ID # yet because it hadn’t been populated. Also, they told me that my daughter was actually not even enrolled on my plan.

WHHAAATTT???!!!!????

I just about lost it. I had spent hours on the phone with Florida Blue confirming that she was on the insurance. There was nothing else Florida Blue could do, I had to go and call the Marketplace to make changes.

I finally spoke to someone at the Marketplace and they explained the situation that my daughter was on the application, however, was not added to the plan and that it was an error on their end. So, I had to spend 3 more hours on the phone with the Marketplace again to re-do the application, get my daughter added and then had to wait and speak to a level 2 customer service rep to get my daughter’s insurance backdated to January 1 as opposed to February 1 since I was doing this after the cutoff date. This entire process took nearly 5 hours on my Saturday.

I called Florida Blue back today in order to get my member ID because I need prescriptions and labs done. Finally, they had my member ID and I asked out of curiosity if my daughter was added…..and she was!!!!

It was the first piece of good news I heard from an insurance company in a really long time.
My advice to others who go to the Marketplace for the first time is ask a million questions, confirm things hundreds of times, get names, employee ID #’s, extensions, speak to managers, do whatever you need to do in order to ensure that your information is being handled properly.

After over 10 hours on the phone with insurance over 2 days, I think everything is good to go. Until the next phone call.

Open Enrollment Season

Yesterday that good ole’ packet about open enrollment came in the mail. For the past 3 years, my wife and I have not changed our plans and I don’t plan on doing so again this year, even with the new addition to the family. The only part about open enrollment season that worries me is, how are my expenses going to change in the next year.

In 2013, I used Apidra because it was $50 for a 90 day supply.

In 2014, I then switched to Novolog because Apidra went up to $150 for 90 day supply and Novolog dropped to $30 for a 90 day supply.

In 2015, I switched to Humalog because Apidra stayed at $150 for 90 days, Novolog went up to $150 for 90 days and Humalog dropped to a whopping $12.50 for 90 days worth of insulin.

So, 3 years, 3 different insulins all because the costs changed dramatically. I never know going into the next year what insulin I am going to be using.

The same goes for my test strips.

I have gone back and forth between One Touch and Contour strips for 3 years because of the large difference in costs. It would be nice to be able to choose which strips and insulin I want to use based on my personal preference and not on what my wallet can afford.

So, just for my own curiosity, I wanted to see how many others have had to change their insulin and/or test strips every year based on the difference of costs from year to year.

[poll id=”2″]

[poll id=”3″]

My Denial and Approval Process of the Minimed 530G

As some of you may know, I was offered a free trial of the Minimed 530G (Disclosure Post) and have been using it ever since. Once the trial was over, I made the decision to stay on the 530G system and the process of getting it covered by insurance was about to begin. And it was a long process.

After the first submission to UnitedHealthcare, it was denied. I received a phone call from my local Medtronic rep, as well as the marketing team at Medtronic who was working with me throughout the trial process and my endo. They all explained to me that this was a very typical response the first time around, but that they were going to submit a letter to the insurance company to get an approval the second time around.

However, the team already knew that the second claim was going to be denied as well. They explained to me that usually it takes three attempts and then after that third attempt is when it finally gets approved.

Long story short, that’s exactly how it happened.

Normally, I would have been pretty upset and irritated that every time I received a letter from UHC, it was a denial letter. But, for the fact that I already knew I would receive these denial letters, it made it a lot easier. Also, the fact that I just had to sit back and do absolutely nothing and that my healthcare team and Medtronic themselves were working for me, was pretty comforting.

After that initial denial letter, I was sent the following PDF from the Medtronic team that outline the documents needed from your healthcare professional and the appeal process and what you can do to speed up the approval process.

Download the MiniMed® 530G with Enlite® Coverage Tool Kit

Now that the process is over and the system was approved and that I have received the product in the mail is very exciting. I can’t wait to get it all set up and start using my own instead of the trial demo product.

A Deductible and Double Co-Pay Later

My saga with OptumRX is over, at least for this go round. As my previous post mentioned, I’ve had a very difficult time getting my insulin re-order. As an update to the previous post, I have received all the insulin that is needed.

I ran out of insulin and needed to go Target in order to fill my retail prescription because the mail order did not ship in time. I decided I would pay the $100 deductible because I needed the insulin, however when I went to pick it up, they couldn’t process the order because it said I just had the mail order filled.

If you’re getting confused, sorry, but this is how it went down. The pharmacist had to call in for an override which took another 15 minutes.

Finally, I had my insulin from Target which is a one month supply, now I just needed my 90 day supply delivered.

I did not get the delivery the next day, so I called and the RX was still being processed which I don’t understand how it takes that long when I had a RX on file, but just ran out of refills. And why does insulin need refill limits anyway, it’s not like I’m going to stop using it any time soon, but that’s a different story for a different time.

I received my delivery of insulin yesterday so I am good to go for insulin for the next 4 months. Which means hopefully I won’t have to deal with Optum for another 4 months.

Over the last 12 months I have had a mail order get delivered to wrong address, test strip order be delivered with half of the 3 month supply damaged and the test strips on the bottom of the bag, this fiasco, Humulin N delivered instead of Humalog.

And that has all been with OptumRX. To say that they are probably the worst mail order pharmacy is an easy choice.

Oh OptumRX – Why Must it be a Hassle

As you may remember, I went about 18 months without insurance.  During that time I had to buy strips and insulin out of pocket and I also received a lot of items from people throughout the DOC because of how awesome everyone is.  One thing that I didn’t have to deal with during that time was insurance companies and mail order pharmacies.

Since I getting insurance back after getting married in July, I’ve been dealing with OptumRX as the mail order pharmacy and it has been nothing but a nightmare.  I really hate having to complain about companies on the blog, because I want to keep things positive and not just reflect on the negatives, but some times, you hit a boiling point and something needs to be said.

In just over 6 months of dealing with OptumRX I have had the wrong type on insulin shipped, the correct insulin shipped, but the wrong amount, having to change my password everytime I login online, prescription refills not being listed on the website so I have to call and wait on hold, 3 faxes from doctor before they finally “received” it, and now… this.

optumrx-damaged-stripsoptumrx-damaged-strips2

Yes, that is how my test strip order was received.  This is the order that took almost 3 weeks because they were not receiving the fax from my doctor. I did run out of strips and was using some leftover Contour strips that I had during this time period, which is primarily my fault for thinking that I could get more strips within 1-2 weeks. I was excited to get my first order of the Verio strips so I can continue to use the meter after I only had 10 trial strips to begin with.

This isn’t just a full blown bash against OptumRX.  I did call them right away and after speaking with 4 different people, they told me that they would send me replacement boxes with a return label to return the damage ones. I was told, “we will just ship them regular mail because some of the boxes weren’t damaged.”  Even though that statement is correct, I don’t know if it’s just me, but when you screw something up because of poor packaging, I shouldn’t have to wait another week to get it back.

All in all I can’t stand having to pick up the phone to call OptumRX for something.