The Great Insurance Paradox



Infertility has acquainted me more deeply with the "ins and outs" (pardon the very bad pun) of the ever fascinating world of medical insurance. First, I learned to speak a new language so I would understand the medical speak Dr. M liked to bombard me with. Then, I educated myself in the terms and conditions of the State Employees Health Plan as to save every dime I could in pursuing Baby Wilson.

Let me just put this out there: dealing with insurance sucks. I am sure this is the case for everyone, no matter what health condition you are handling. I'm sure the good people working the helpline for my insurance carrier really are good human beings. But, boy oh boy, the policies and procedures of the insurance company make getting a straight answers out of them next door to impossible.


Let's talk about the 2 1/2 hours of my life I will never get back again. When I first met with Dr. D back in the summer, I decided I would call my insurance provider. He wanted to try differentt treatments, so my Type A Personality took over. When I checked the insurance website to see about drug pricing, I was directed to call the company's helpline to see which drugs were preferred and which drugs would be more expensive under my coverage.  OK. I'm on board. So, I get out my handy-dandy pink infertility notebook (#2, Dr. S, I've already filled up #1 I started with at your office) and my pen and get ready for automated phone call purgatory.


After calmly, then aggressively, and finally manically talking to the automated system (OPERATOR!! YES OPERATOR. No, NOT appendectomy!!! UGH) I actually get a human being on the line. She notifies me that the number I have called is not the correct number for drug authorizations, so I need to speak with someone in a different call center. Thankfully, she put me through to the call center, where I went through the same litany of automation-for -my-convenience. Then, my helpful customer service rep came on the line.


To say that she hated her job would be an understatement. She "huffed" in my ear at least half a dozen times and answered none of my questions.  After asking which drugs were preferred from the list, I was told she couldn't give me any information until my doctor called in the information to a pharmacy and the pharmacy called the insurance. But, the pharmacy said I needed to talk to my insurance about the prior authorizations that were needed. Yes, the CSR told me, I would need prior authorization for any fertility med. But, she would not tell me which drugs would be covered under authorization until the doctor ordered a drug.
At this moment, I was pretty sure the only winning move was to not play the game. But, as that was not an option, I endured. It was a chicken and the egg scenario and I just wanted to cry. Eggs just aren't something you mess with when you're infertile. 


In fact, though I am a kind hearted person, I think I know why the US Government uses water boarding. Seriously. I truly believe these people would only give a definite answer if there was a clear and eminent threat to their life and safety.... and in truth, I'm still not sure they could or would tell me under what circumstances certain drugs would be covered even in the most dire of circumstances. If we need someone to keep our national secrets, the CIA should start recruiting from the insurance help lines. These folks will likely die before giving up the info on Gonal-F versus Follistim.


I hung up from the call, totally defeated, with no more information than when I started the process. However, my irritation with insurance companies was far from over.
Jeremy and I recently met with my Fertility Clinic nurse to learn how to give me injections of the hormones I will need to increase my egg production. So, it's go time for ordering the meds. Here's where two of the most asinine policies I could ever dream up came into play.
One cycle worth of IUI hormones costs between$1000- $4000 out of pocket with no insurance help. There are no cheaper alternatives. So, I read that my insurance will cover these drugs in "certain cases." Oh no... more helpful phone calls.


This time our nurse beat us to the punch. She notified us that our insurance prefers the drug Follistim, which happens to be the Lamborghini of fertility drugs. Seriously, we're more in the compact to mid-size domestic car price range as teachers. Why does the teacher insurance "prefer" the most expensive drug? Nevertheless, she trained me on how to use the "pen" the drug is administered with. {author's note... it's not a pen. It's a needle. A needle encased in a snazzy plastic pen holder, but it's a needle.} I felt like I, the needle-phobe, could do this thing for real. I made it through the training and was ready to get this show on the road.
Then, my nurse threw one more absolutely ridiculous curve ball at us. My insurance, though it "prefers" Follistim, will not cover any drugs if they are prescribed as part of ART, or Artificial Reproductive Therapies.  In short, if you use the drugs for the procedures they are designed for, the insurance company will not cover them. She wasn't sure what Dr. D said our prescribed course of action was, but if it included IUI in our plan, she would be required to tell the insurance and they would deny any coverage for drugs, leaving us to foot the entire bill for the procedure and drugs.


In truth, our plan (meaning the plan my husband and I have) is to have an IUI, but as I have learned on this long and winding road, the best laid plans of mice and men oft go awry. In truth, if I have too many mature follicles, the doctor will not want to do IUI. If I don't respond well to the drugs, there will be no reason to do IUI. If we somehow miss the right window of time, there will be no IUI. So, who in the world knows if IUI is really in my plans. Does the doctor say I need it to get pregnant? Probably not because they can't tell me what I need to get pregnant. If they could tell me that, I would pay for that and be pregnant already.
Don't get me wrong, I know this is a first-world problem of the highest order. But, in a time when I go to work every day and pay the insurance premiums diligently, is it too much to expect for an insurance provider to give me some kind of service? I already know they will not cover the most effective treatment for infertility---IVF. If we get there, we are 100% on our own for the entire bill. But, when the only different between IUI and the "old fashioned way" is a catheter and a plastic cup, it seems ridiculous that the insurance company will not pay for drugs for one when it will for the other. In truth, the IUI is a clinical procedure. The other definitely is not.


So, we are sitting here, knowing that next month we are looking at our first injectable IUI (maybe, probably, hopefully) without much support from my insurance. I could make myself ok with this if I though it was limited to me, or to only teachers in North Carolina. It's not. In fact, I have heard from teachers in several states that this is the exact policy of their insurance. Yes, we have decided to devote our lives to children... so let's make it more difficult for teachers to get pregnant. My sarcasm translates here, right?


Also, one final insult is the last large group I know who falls under this insane policy--- the United States Armed Services. The men and women who serve us, as well as their spouses, put everything on the line for our countries. When it comes to paying for some drugs so they can have a family, if it includes ART, it's too much to ask. Seriously. We ask them to live their lives in the most dangerous situations possible and we can't foot the bill for a drugs for an IUI? There's just no justice in that. 


All of these decisions stem from political choices we have made along the way. I don't like to talk politics here, because I know some of my family members wholeheartedly love me and fundamentally disagree with me about politics. But, I don't care which side of the aisle you are on, you have to admit the logic behind these policies that affect millions of Americans is nothing short of ludicrous. So, the next time I share those updates from RESOLVE and ask you to support family building legislation, remember it's not just me you are helping. It's millions of Americans who, like me are hoping, wishing and waiting to start their families. It's injecting politics and bureaucracy with common sense that it so often lacks. It's opening up hope to people who need it in short order.





Comments

  1. {Hopping over from Amateur Nester link up}
    So wait. Follistim- a drug that's used for infertility is covered by your insurance, but if it's used for infertility it's not covered. That is the most insane thing I've ever heard!
    The insurance through my employer only covers IUI, but we need IVF The insurance through my husbands employer does cover IVF, so we are on their policy instead. But that does make me angry mine will cover only IUI. For me, I see it as you will only cover SOME peoples infertility but not all. It's not fair. I'd rather them cover all or nothing.
    Good luck to you with everything!
    xoxo danielle
    wallacefambygodsgrace.blogspot.com

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  3. I think that was unprofessional of the customer service representative. It was her responsibility to answer any question you had with regard to your insurance, and it was rude of her to exclaim her disinterest regarding the matter. At any rate, I do hope you got through to the insurance company, and that your claim has been approved. It would be difficult without their help, after all. Keep us posted, Becky. All the best to you! :)

    Joshua Duncan @ Focus Insurance

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  4. Dealing with insurance can be quite irritating. Anyway, I’m sorry that you had to go through that unprofessional CSR agent. I hope you encounter a better one, should you need to call again. Anyway, thanks for sharing this with us. Take care!


    Steven Keltsch @ Allied Insurance Manage

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  5. I know how it is with insurance companies. I never had to call myself to find out information about what was covered and what wasn't though. Luckily, my doctor took it upon herself to push through all the needed authorizations just so I could have a test done. My husband I were also dealing fertility problems.

    Joey @ Amerika Link

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