T Nation

Insurance Co-Pay Farce

So I started doing injections of Testosterone Cyp back in September. Since my first clinic visit after my initial Total Testosterone results (mid-90’s), I have heard one reoccurring theme over and over, “Hopefully, your insurance will cover injections.” I sort of picked up on the importance of this, and when I received my first script, I was anxious to see whether it went through. Sure enough, it did not and popped back that I had to have a pre-authorization for it to pay. So I paid out of pocket, which it seems like it was maybe $125 for 10ml of 200mg/ml. I felt so bad at that point and was so frustrated by my initial difficulty at getting a script from the first clinic I visited that I was determined a shot was happening that evening one way or another.

Around December, when my first bottle began to run low, I contacted my doctor about filling out the form for the insurance. Then, I had to call the insurance company to send the form to him. He fills it out, and I call the company to see if everything was now good to go. He send me a message that says, “The insurance company just gave us notice that you are now approved.” I’m thinking I’ve won the battle and feel good about going to get the script filled. Off I go to the pharmacy that day, only to find out that it is still not going through. I think it maybe just takes some time to process, and I return back in a day or so. Still won’t go through. After a discussion with the pharmacy, I call the insurance company again. Now, they say it is not approved because it is “FDA contraindicated for me.” I understood what I thought this meant, that perhaps something about my health or another script I was on was preventing it, so I ask what specifically was the contraindication. The insurance rep says there is no way for her to know. I admit, at this point I get kind of ill and ask how exactly is it possible for me, the covered person, to be unable to find out what exactly the reason is that my insurance policy will not pay for the prescription. She says that there is know way to know that. Knowing this has to be crap, I tell her that I understand she does not know, but who can I speak to that actually makes this sort of determination. She says that I cannot speak to anyone about it, but my doctor can call them and request a “cohort conference” with them to discuss it further. This is naturally a Friday afternoon, and my doctor was out and would not be in until later the next week, due to holidays. I gave her sort of verbal parting shot and hung up.

Then, I call the pharmacy where the tech tells me that he found a “discount card” and my cost would only be around $85 for the bottle. I tell him to get it ready, and I’ll be by to pick it up in a bit. I then remember that a pharmacist friend of mine had a social media post comment about using the GoodRx app to get some really great price on whatever the person was needing who made the original post. I then download the app, and sure enough there is a code to get the script filled for around $65 for the bottle. I call the pharmacy and give them the code. I go by and pick it up that afternoon.

Now, at that point, I’m mad and in full “pissing match” mode about my insurance. I decide that I am not going to let it die. I send a message to my doctor pushing him to make the call to do the conference with them or whatever. He says that it should now be approved. A couple of days later, I receive a letter that says my insurance has approved my coverage. I’m pretty happy that finally this is all over, and I can get it all covered. Then, a couple of days later, I get two letters in the mail from the insurance company. I open it up to find that the first says my insurance has denied my coverage. I’m so pissed at this point. Then, I open the second and find that it state my insurance has APPROVED my coverage for the script. Confused, I begin to look at all three letters a little more carefully to make sense of this, as it is the late evening, and I couldn’t call them. The first approved letter was actually dated a week or two before the second two. The second one saying I was not approved, was dated a day or so before the third letter, which stated I was approved. Apparently, due to the holidays and everything along with the time to process the letters, I was basically just receiving mail that reflected the three stages of approval, disapproval, and approval I had already experienced.

The next day, I decide just to call my pharmacy to have them go ahead and run the script to see whether it actually goes through. I tell them I am not purchasing today, but let’s just do it to see. They run it, and sure enough it is approved! I’m psyched that I have finally won the long, epic conflict between myself and my insurance. Truthfully, I was feeling pretty good with the, “Those insurance suckers just didn’t know what kind of truly stubborn person I was going to be, but they learned their lesson!” attitude. I then explain again that I’m not going to get it today, but I ask how much the co-pay is going to be for my part. He punches it into the computer and says, “Your going to save a good bit, your part will only be $85.” I hang up and bring up the GoodRx app again, now they have a new code for same bottle of Cyp, you can get it for $58.

There are three morals to this story:
First, America’s healthcare system has real issues, whether you are a Democrat, an Independent, or a Republican, it is still 100% true.
Second, in our country the health insurance company ALWAYS wins the war, even when you think you have won all the big battles.
Third, use GoodRx, it’s a really good app.

:wink:

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You sound stressed. Might be due to low T.
:wink:

I know, it’s the principle. I would have gladly paid the $125. The funny thing is, if you add up all the time (money spent for personnel to process this) spent fighting over this claim, phone calls, letters generated, etc., it probably would have been cheaper for them to just cover it. I suppose, to be fair, you’re the one out of 250 who fought it as far. Be thankful you do not have a potentially terminal illness or are in need of surgery being denied by someone on the other side of the country.

Insurance companies are in business to collect premiums, not pay claims. They hire people to review, and deny whenever possible, claims. Doctors and hospitals have to hire people (insurance department, coders, etc.) to fight to get paid with doctors spending time arguing with claims adjusters and other doctors hired by the insurance company to limit claim exposure. You doctor may have spent more time fighting with your insurance company than he did face to face examining you!

This will not change as long as someone else pays for health care. Does not matter who it is. The government paying for it will be much worse.

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