Just when I thought I had experienced the worst possible scenario imaginable in dealing with EXPRESS SCRIPTS/TRICARE, now I find that I had only seen the tip of the government bureaucracy's dictatorial attitude in action. It gets worse!
In the last installment, if you remember, my wife's nurse spent twenty-two minutes on the phone with EXPRESS SCRIPTS's pre-admissions interviewer describing the problems my wife had with the generic form of the prescription medicine that she had been taking for years, and we had been turned down.
The next day, (last Friday was a week ago), after hearing that we had to go through a clinical appeal process next, my wife wrote the letter to her doctor asking her to negotiate with EXPRESS SCRIPTS and make the appeal for the name-brand medication. My wife's doctor then had to write a letter to EXPRESS SCRIPTS giving them the medical justification...AGAIN...for my wife not taking the generic medication (e.g., severe stomach cramps and other complications) and telling EXPRESS SCRIPTS that my wife needed the name-brand medication. All of that was then faxed to the clinical appeal department at EXPRESS SCRIPTS.
All of that was completed and faxed to EXPRESS SCRIPTS before close-of-business on Friday. Monday morning, I called and tried to verify that EXPRESS SCRIPTS had, in fact, received the faxes, but by mid-afternoon, there was nothing in the system to tell me that it had been received. Tuesday, same result, so by mid-afternoon, I decided I had had enough of this. I had, by then, been trying to fill my wife's prescription for nearly three weeks, and had been denied twice. As one can imagine, we are approaching my wife running out of the medications, and I am really now getting frustrated by this situation. In my mind, I am hoping against hope that we finally have gotten beyond the local people and are now at corporate HQ in St. Louis, MO., were someone certainly would see the lunacy I have been having to deal with.
I called the President of EXPRESS SCRIPTS in his St. Louis Headquarters around three PM on Tuesday, got a recording, and left a message that I expected a call back within twenty four hours. Surprisingly, I got a call around five PM from someone in his office, who was very understanding when I expressed my concerns. She said she would look into it and call me back before close of business on Wednesday. She did call me back that next afternoon and told me that the documentation was received and someone would be looking at it as soon as they could, which could be anywhere from one day to a couple of weeks! I explained to her that a delay of that long was not acceptable, that I had been fighting this for nearly two weeks at that time, so she said she would see what she could do.
Sure enough, the next afternoon, I got a call from that clinical appeals department telling me that the appeal had been turned down! I went ballistic on that gentleman, explaining to him all that we had been through, and asking him how they could come to such a ridiculous decision, to which he gave me a sluff-off, saying that I would receive a letter soon (now nearly a week later and I have not received that letter!) explaining the decision, and explaining that there was one more appeal that I needed to go through. I told him that I would be seeing my lawyer and we would see about another appeal.
I called back and got the young lady in the President's office who was quick to tell me that she did not agree with the decision, but that it was out of her hands. She explained that I had to file another appeal with an outside agency looking at the facts, and that hopefully that person or group would make the right decision, but that I could not do that until I received the letter, and she could not tell me how long that would take. When I asked her what justification they gave for turning our appeal down, they said that they wanted my wife to try a different generic! OK...so let us make my wife a guinea pig and see if maybe she will not have as bad a reaction to a different generic so we can save a few bucks! Not in this lifetime! These people are unbelievable. They really could care less whether or not my wife suffers any bad affects while they experiment with different generics to save a few bucks. This is what the rest of America has to look forward to as Obamacare become the nation's health care standard that the rest of the industry must comply with.
So...here we are, four weeks and two appeal turn-downs later, waiting on a letter from EXPRESS SCRIPTS telling us about the final appeal process we must go through. All of this over a prescription that sells retail for around $49 without insurance, versus a generic priced form that sells for around $25.00. I hate to think what I will have to go through if I ever have to have a name brand expensive drug!
I spoke to a lawyer; I will probably have to file suit against EXPRESS SCRIPTS/TRICARE because of this problem; at this point, I really do not believe that they are going to reverse their decisions; I have probably aggravated too many people, but right now, I do not care. I will not have my wife treated like a guinea pig. I will not take the risk for my wife have to suffer in some clinical trial when I already know that there is a product out there that does not give her any side affects. It is my and my wife's decision, NOT some bureaucrat sitting behind a computer that would not know us if we walked up and hit them square on the chin (which right now would make me feel MUCH better! So, here I am, a retired Army officer, on a fixed income, having to decide whether to take what little disposable personal income I have and pay a lawyer to represent me, or knuckle under to the system and let them treat me and my wife like some sub-human species and take whatever crumbs they want to throw me. NOT!!!
Get ready, America. we have an expression in the military; it is called BOHICA (Bend Over, Here It Comes Again). Uncle Sam is going to take away every decision that a patient and their doctor make together and force it to be passed in front of an individual or group of bureaucrats that are more concerned with enforcing cost reduction policies that other bureaucrats have decided is best for the country. Decisions are already being made on not what works for the patient, but what costs the government less!
· Imagine what we can expect when it comes to whether we need an expensive operation or life-saving treatment? Before we can get the treatment, the "board" will have to review the symptoms, the medical files of the doctors providing direct treatment to determine if that doctor has considered all the less-expensive options in treatment before the local doctor can proceed.
· How many doctors will put up with this type of BS? Expect a flood of doctors to tell Uncle Same to go stick his healthcare program where the sun does not shine and go back to the way things were before insurance...cash up front or an agreed upon payment plan financed by the patient and not the insurance companies. The costs will be lower, patients will flood to these doctors, but they will not be able to keep up with demand.
· People who cannot afford to pay cash or finance their own treatments will be forced to compete with the now shrunken supply of doctors, and the available of fast, quality treatment will diminish. There will be longer delays, and people will end up dying before they can get to the doctor for treatment.
Watch out, America. Big Brother's healthcare plan is here, and it is a disaster already. Imagine what is coming, if I have to go through this kind of bureaucratic hell for a $49 prescription! GOD HELP US!!!
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