I am a do-er. When no one else will do something, I will. A confrontation? I guess I'll do it. A legal battle that a lot of people would take on if they could? I guess that's mine, too. I have so many whines, things I kept thinking I should write about here and now they're all jumbled up. Imma take on one at a time. Forgive my typos. I'm on my phone, in bed, because i can't sleep.
My medical insurance.
I have taken a medication called Provigil since 1999 for idiopathic hypersomnia (aka primary hypersomnia). It is a non-amphetamine stimulant, not exciting to abuse like Adderall but sometimes abused by college students or professionals seeking to maximize their attention and wakefulness. Not me. I take it so that I won't fall asleep while driving. It is also secondarily used as an adjunct for the depression side of my bipolar disorder. Provigil is only labeled for narcolepsy, sleep apnea, shift work sleep disorder (and maybe MS related fatigue). However it is very commonly used off label for idiopathic hypersomnia (IH). CVS Caremark (CVS) requires prior authorization (PA) for any Provigil prescription.
Two years ago, it took 2 months of fighting. The meds would cost me approximately $3,000 a month to pay out of pocket. In the ridiculous battle that had my arguably expert physicians (one of whom literally wrote the book on this stuff) having to defend their clinical actions to rural psychiatrists who admittedly never have seen a single sleep disorder, I was left without meds for a month, saving CVS tons (not the full $3K I'm sure, but it was a nice chunk of change, I'm sure). I finally won when it got to the external level with the reviewer saying that it was OF COURSE medically necessary and consistent with the standard of treatment.
Last year when they told me I needed to get PA again, I called in a hysterical suicidal rage and told them that they were fucking with people's lives, that this is a psychiatric med and they know I have a history of psych hospitalizations. I told them that it was clear CVS chooses money over patient welfare and that they had blood on their hands. I asked them if I needed to come down there and show them my blood on my hands for them to see what they were doing to people. This was at 4:15 pm. The next morning I got an automated call telling me that my request had been approved. What took 2 months 2 years ago took 1 day last year.
This year it starts up and I find a law that says if my doctor is prescribing led for an off-label use and it is something that has been covered in the past, I simply need to provide 2 research articles that demonstrate the safety and efficacy (effectiveness) of the med for my condition. I researched laws like crazy and I researched drug studies line crazy. I know all about the laws regarding coverage of medications and I know aaaaallllll about the Provigil research. Then I called to get a copy of my records so I could see how and why I was approved last year. I was told that they would "never" give me my records.
HOLD UP.
This is in complete violation of my civil rights as protected by HIPAA. Just as fiercely as HIPAA a protects me from having my healthcare information shared without my consent, it protects my right to have access to my healthcare records. So I started a battle with them over that, filing a complaint with the Office for Civil Rights. I researched the privacy laws, access to records laws, federal laws, state laws, penalties for violations, etc. Over the course of a month, I had numerous reps first tell me that my records were on the way and then ultimately that they were never coming because it was CVS's policy to not release records. Not only that but they knew I was waiting for those records to file my appeal this year and it's not crazy talk to say that it appears they may have been trying to stalk that so theat I am eventually left without meds for a bit again this year. Cases like mine almost without exception prevail once they get to the external review level but they count on people giving up before they reach that point.
But back to the PA part of this. So I gatheted 9 articles. I wrote a 13 page cover letter that cited the laws that order them to give me my motherfucking medication simply because my doctor has ordered it (as long as I can find 2 articles to support the safety/efficacy). I attached approximately 50 pages of the actual journal articles.
1) I also have OCD
2) I'm Italian-American
3) I'm a Scorpio
4) I'm smart
5) I'm resourceful
6) I know how to research (thank you, dissertation)
A few days later I got the automated call that my request had been approved. I called to ask how long it was good for since it has always only been for 1 year at a time. The girl said, "It says here 'lifetime.'"
SUCCESS!!! SCREW YOU, BIG INSURANCE COMPANY!!
After a month of harassing them and making complaints to the Office for Civil Rights, I finally got as much of my records as I think they will ever admit as existing. I'm pretty certain there has to be more to my record but I can't prove it so this will have to do.
This is really only part one of my jailhouse law education but it's 1:50 am, I suck at typing on my phone, and I'm hoping that im actually sleepy now. I swear I'll fill in more soon.
