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Insurance Companies Are NOT Psychiatrists–Why Are They Making Decisions?

You have had asthma as long as you can remember–since childhood–and have been seeing the same pulmonologist for at least three years. Your doctor has had you on theophylline, a pill you take three times a day, and a Flovent inhaler (which you use twice daily) for the past year. You went to the pharmacy today and dropped off your scripts, as you do every month, only to be told you can’t fill them. Why? Because your insurance company won’t approve a prescription for more than 60 theophylline. Nor will they fill a Flovent inhaler for more uses than once daily. insurance1

Nevermind your doctor increased your doses two months ago to help you deal with the allergy season, which sends your asthma into overdrive. Nevermind your doctor wrote the prescriptions for the dosage she recommended based on your symptoms and medical history. According to your insurer, because most asthma patients in your sex and age group only take two theophylline a day and use their inhaler an average of once daily, you should be able to get by on the same doses. According to your insurer, you’re simply a hypochondriac who’s over-medicating and wasting money. So now you’re waiting for your doctor’s office and the insurance company to work it out, and in the meantime, hoping like hell you don’t have an attack because you are completely out of your medications.

Are you furious yet? I am. Because this is exactly what I am dealing with today. When I left my job, we switched to my husband’s employer-provided insurance plan, Coventry of Kansas. (Yes, I’m naming names. I only protect the innocent.) Yesterday, I submitted new, handwritten prescriptions for Bob’s four medications. Of the four, only two were filled, because he is “over their approved dose limit” for Seroquel and Focalin.

Oh, really? Take me, please, to the genius who made this decision, because I’d like to leave unmedicated Bob with them when his last Focalin wears off this evening. And tomorrow, when the school calls me to come get him, I want that person to go pick him up.
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Who are these people who get to decide what medication we take and how much? Not the physicians we’re paying $100 (or more) a visit. Why bother going to a doctor at all? Next time you’re feeling poorly, just call your insurance company–they apparently have the power to diagnose you AND determine your best course of treatment, all without seeing you OR your medical history.

The good news? My husband’s employer is switching to a different carrier (the one my former employer used, in fact). If we can make it through the end of the week, I should (hopefully) be able to get Bob’s prescriptions filled as written. And happily tell Coventry of Kansas to kiss my asthma.

ED. NOTE: ConcernedMom (see comment below) agrees with the insurance company and says Bob’s psychiatrist and I over-medicating my son. Watch my response: We’re Not Trying to Drug Our Mentally Ill Kids Into Submission (Video)

23 thoughts on “Insurance Companies Are NOT Psychiatrists–Why Are They Making Decisions?”

  1. How does a child so young in the prime of his development take four different medications? How is it legal? Sounds overmedicated to me. The medication causes so many problems, health and otherwise. What psychiatrist allows this? It is unethical any way you slice it. How would you possibly know who Bob is with all those meds in him!? If that’s what it takes to keep him in school, you may want to consider taking him out, or switching schools. Insurance company is right this time, I’d say. Too much is too much–I don’t care what the diagnosis.

    1. @”concernedmom”–

      Have you READ any post in this blog (or anyone else’s blog on this site) other than this one?

      Because I have to truly wonder based on your comment.

      And sadly, I’m sure you’d probably be the first concerned parent to (1) demand my son be removed from his school, (2) point the finger at me as being to blame for his behavior, and (3) sue me and the school district for damages after unmedicated Bob tries to stab your child with a pair of scissors for no reason, other than that your child was making a noise Bob found irritating and refused to stop after Bob asked him.

  2. Concernedmom–I am grateful that I am not left completely speechless by your asinine comment because I want to make sure that you realize how asinine your comment was. I will not break down your comment to point out each and every fallacy. I ask that you please think before you voice your thoughts on anything, especially how other people raise their children. And medicating? Do you know what asthma is? Do you know Bob’s history? Please practice writing in your diary before you comment on blogs again. Please.

  3. I’m sorry you are having problems with your insurance company. Th docors should decide what medications each person needs and cover it. I can see if it is to soon for a refill, but I don’t think that is your case. I hope he can hold out until your new insurance kicks in.

    Michele

  4. Amazing lack of insight @concernedmom. But that’s not important.

    I was working with my doctor on a treatment plan and was told by my insurance it was good enough & they would not cover me for my disability claim despite med records supporting my actions. Separately they approved almost 250$ in private physical training.

    1/ It was mental health I needed treatment for and they would not approve bc my plan was not in line with their preference. But they can pull 250 out for something not directly related to my illness? Huh?

    2/ I could not afford the treatment I needed because they would not approve my claim.

    Seriously major problems in our society when bureaucracy rules over common sense and imperaonal corporations have more rule over our health than our health care professionals. What an impossible job good practitioners have.l

  5. Concernedmom is taking a generalized opinion and applying it to a specific case. That is almost always a dangerous way of responding. In general, statistically, there is a good argument that, as a society we are over-medicating our children. And our adults. But psychiatric medications control symptoms, which is both their blessing and curse. For children, who really really need to have symptoms controlled in order to do their tasks as children and in order for the adults around them to guide them through childhood, under-medicating is much more dangerous than over medicating. And after just a few readings of your wonderfully honest posts, I think there is not doubt that you are expressing valid and validating opinions. And doing the right thing for you son and family.

    From age 14 to 24 my son survived only because of cocktails of pysch meds. Now, as an adult, he is just beginning to think of how to reduce them.

    When my insurance company approves narcotics for my migraines but not the non-narcotic medications I wonder if there is any reasoning beyond saving money.

    Ari

  6. They r not your dr. Your dr knows u best! My ins co made me try 2 other meds b4 paying for abilify and now still won’t pay 4 it!

    1. @anonymous–I agree 100%. even our “new” plan, which i started reviewing last night, HEAVILY pushes their “tier 1” drugs. as if to say, “you don’t need effexor, you’re just a prima dona who thinks she needs the expensive stuff. why can’t you just take good ol’ cheap sertraline like everyone else?” it’s insane. pun not intended, but fitting.

  7. Even if the people making these decisions were physicians, no doctor worth their salt would prescribe a medication without seeing or even so much as talking to the patient or getting a complete history. If a community doctor did that and got caught,would they not be brought up on ethics charges, or, if something went wrong as a result of doing this, malpractice? These insurance companies seem to be untouchable because their power lies with the amount of dollars they bring in, not the lives they save.

  8. Holy smokes! the old saying about walking in someone else’s shoes holds true. A while back I was taking many psychotropics which I doubt I would have lived without at that time. My insurance company recently stopped reimbursing for one of those medications. They also refuse to pay for an asthma medication.

    I hope that Bob and his mom do OK and that the ins. company pays for the proper meds.

  9. All you have to do is go to a state facility and use tax payer’s money and you can get any medication you want no matter what the cost. My own insurance company makes the drugs they get almost out of anyone’s budget…$10.00 a pill!!!!!! But private insurance has sorely under-represented the mental health needs of people and pays their doctors so little that… no one with insurance can see a mental health provider unless you pay cash for the visit. It isn’t covered nearly as good as medical. Major mental disorders are medically based this day and age. If several of our child murderers had been able to see a mental health therapist as often as they needed, maybe Columbine never would have happened!

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