anyone know ins and outs of rx insurance? "the doctor has not answered

[mopinko]

question #1" is all the answer they will give me as to why they will not cover a drug that i have been taking for a while. they won't tell me what question #1 is. they have whined about it in the past, but have been pacified eventually.
i suppose i could ask the doc, but i have a kinda strange relationship with him, and suspect he would not answer the question completely honestly.

[dixiegrrrrl]

1. Since you don't know the question, no one else except the doc does either.

Ask the doc.
Also ask the doc for a generic drug if there is one.
And let him know his completing paperwork is necessary for a satisfied patient.
YOU have to complete paperwork for HIM to get paid, yes?

[mopinko]

3. already taking the generic, and

doc has tried his best, his nurse tells me, to figure out what they want and give it to them.
and like i said, doc is a funny guy, and not very loose with information sometimes. i am not all that crazy about him, honestly, but, well, it's a long story.
and no, there really isn't much paperwork on my end. he has the numbers, they send the bill, he gets paid in a couple of days.

[Ms. Toad]

2. Question #1 would likely be something specific to your

insurance company. I doubt anyone besides the insurance company or your doctor could tell you. Likely a diagnosis, or specific test. My insurance covers some drugs for specific diagnoses, but not others.

My insurance company also cover some medications only if certain test results come out a certain way - if the doctor fails to run a test (even if the doctor has run a more sophisticated test) they refuse to pay for it. My daughter had a systemic fungal infection once (that her GP insisted for months was just her picking at a sore) The ER doctor recognized it as a fungus immediately, cultured it and found out specifically which anti-fungal medication it was susceptible to. Insurance company refused to pay for it because the ER doc had skipped the preliminary test (since by the time we ended up in the ER the infection was so bad that immediate treatment with a systemic medication was necessary to prevent more severe long term damage).

The grunts processing denials don't necessarily know anything other than that the paper from the doctor doesn't have the specific diagnosis or test they are told to look for. Ultimately we got to someone who overrode the denial - but it was maddening, particularly since the doctor had done the test to make sure that she quickly got on the right medication to kill the fungus.

[Fire_Medic_Dave]

4. Are you being prescribed the drug off label?

It's kind of rare for them to deny a generic drug that you having been taking for a while unless it is being prescribed off label. Just a thought.

David

[mopinko]

5. nope

taking for the primary condition it was made for.

[Fire_Medic_Dave]

6. Have you called the insurance company?

[mopinko]

7. yep.

they won't tell me what the question is, just that the doctor didn't answer it.