Patients say insurance companies make them jump through too many hoops

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By Jason Stoogenke

CHARLOTTE, N.C. — Patients say they've been taking certain medicines for months, or even years. They say they have a doctor's prescription. But, they say, when they go to get a refill their insurance makes it difficult.

Patient: ‘Drag you down’

Charlotte lawyer Michel Daisley was diagnosed with multiple sclerosis on his 25th birthday. He is about 60 now, walks with a limp and gets tired often.

So he takes a narcolepsy drug, which he says costs more than $300 out of pocket.

"It has helped on days when I go to court or days when I have depositions, days when I know I'm going to need to be alert and not be tired," he said. He needs a refill every other month. And, even though he's been taking it for 10 years or so, he says, refilling it usually is a struggle.

He says many times, after his doctor writes a prescription, he goes to the pharmacy only to have his insurance company refuse to cover it because it is not a typical MS drug. His pharmacy gets back to his doctor, who confirms it's right. His pharmacy goes back to his insurance company, which finally says yes.

"It has been extremely frustrating at times because you're having the answer the same questions over and over and over again," he said. "Sometimes it'll drag you down. Sometimes it'll just tick you off."

  • CLICK PLAY: Hear from Michel Daisley

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Expert: Insurance does this on purpose

Some drug industry insiders say companies do this on purpose to discourage you from getting certain medications.

Action 9's Jason Stoogenke asked Chris Blanchette, a University of North Carolina at Charlotte professor and former drug industry employee, "Do the insurance companies do this on purpose? Do they make it difficult so they don't have to pay?"

"Yes. Short answer's yes,” he said.

  • CLICK PLAY: Hear more from Chris Blanchette

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He says insurance companies make it difficult in three main ways.

  1. They charge you a higher co-pay for the drug.
  2. They require your doctor to call the insurance company and explain why you need the drug.
  3. They require you to exhaust other, similar -- but less expensive -- drugs first.

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Blanchette says the companies hope you give up or at least delay it for a long time.

Three ways to overcome those obstacles

Bottom line, no matter what the reasons, patients can overcome hurdles:

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  • Be flexible. Maybe there's another drug that will work for you; one that insurance may be more willing to cover.
  • Make sure your doctor will go to bat for you because insurance may require that.
  • If your insurance is through your work, tell your human resources representative what's going on. Chances are insurance doesn't want your employer contracting with a different company.

And be persistent.

"Like the Panthers: keep pounding. Keep pounding away in order to get this medication that you need,” Daisley said.

  • CLICK PLAY: More from Michel Daisley

                   

Insurance's response

Stoogenke asked the country's five largest insurance companies -- Aetna, Blue Cross Blue Shield, Cigna, Humana, UnitedHealthcare to respond to these accusations.

None would comment on the record. One told Stoogenke, "Review is not unusual in pharmaceutical coverage. It's to make sure the patient receives the right drug, at the right time, in the right amount for their health condition."

Some of the companies referred Stoogenke to the Association of Health Insurance Plans, a well-known voice of the industry. At first, the Association seemed interested in sharing the industry's side of the story, but then simply stopped returning my emails and phone calls.

Need help?

If you need help paying for medicines, even over-the-counter ones, contact MedAssist.