A Lesson in Health Insurance

Not surprisingly I have been learning first hand some reasons for why we need health care reform. Chronicled here is a long, truthful, hopefully somewhat humorous record of my efforts to obtain 4 doses of a drug I must take following each chemotherapy infusion. The drug is called Neulasta which prevents infections that could arise from having low white blood cell counts. My health insurance provider, TUFTS HEALTH PLAN (I am feeling angry with them. To vent this anger, I will hereafter try to remember to refer to them in ALL CAPS), is very reluctant to fill this prescription because it is very expensive. Actually, I see their point. Each syringe costs $8000.00! One wonders how .6 milliliter of anything could be worth so much. For that kind of money it ought to be curing the cancer.

The manufacturer of this precious substance is AMGEN (not feeling too affectionately towards this company either.) A very brief google search produced the following answer:

"Amgen Inc., the world’s largest biotechnology company, said fourth-quarter profit rose 9.8 percent on rising sales of its top two drugs, Neulasta and Enbrel, and lowered expenses for research and taxes. Net income rose to $1.02 billion, or $1.08 a share, from $931 million, or 92 cents a share, a year ago, the Thousand Oaks, California-based company said in a statement. Excluding certain costs, earnings of $1.17 per share beat the $1.11 average estimate of 23 analysts surveyed by Bloomberg."

So the Neulasta quest goes like this.

Monday, February 28:

Nurse: so your insurance company (TUFTS!) requires that you order your Neulasta from a mail order pharmacy called CURASCRIPTS (another bad guy in this saga). So we will send the prescription to CURASCRIPTSs and they will send it to you in time for your injection.

Amy: (still naive to the potential challenges of filling a prescription): Okay. So all I do is wait to receive the prescription.

Nurse: Right. You may receive it a couple of days before you need to take it. Keep it in the refrigerator during that time.

Amy: Right

Thursday, March 3 (5 days before I have to take the Neulasta)

Amy calls Nurse: I haven't received the drug.
Nurse: (After checking her files.) Well, we sent the prescription to them last week. I will follow up with CURASCRIPTS. Maybe you should check with your insurance company to make sure there are no issues on their end.

Amy calls TUFTS: Can you tell me the status of approval for a drug I need called Neulasta. I was supposed to receive it in the mail through CURASCRIPTS but I haven't received it yet, and I need it by Tuesday at the latest and what with the weekend coming up, I am concerned.

TUFTS: Let's see. I don't think we have received any prescription. You might want to check with your doctor.

Amy: I just got off the phone with my doctor and they told me they had sent the prescription to TUFTS and that I should call you. (The weaknesses of the American Health Care System are beginning to dawn on me.) I will tell them to send it again. Please confirm the fax number.

TUFTS: Very good. I will call CURASCRIPTS as soon as we receive the prescription. Don't you worry, Maam, we'll sort it out.

Amy: (Much relieved and feeling very grateful to this woman who, after all, had no responsibility for the problem.) Thank you so much. What is your name so that I can contact you if I have any further problems since you have been so helpful. Thank you again.

TUFTS: My name is Sue. Please feel free to call me any time.

Amy calls NP: TUFTS is telling me that they haven't received the prescription. I hate to bother you, but could you resend it to the fax number that you already sent it to?

Friday, March 4, 3:00 PM (4 days before I need the shot, 1 business day.)

No sign of a package from  CURASCRIPTS. Who to call now. Lets try CURASCRIPTS.

Amy: Can you tell me the status of my prescription...

CURASCRIPTS: (After 10 minutes on hold.) Hmmmmm. I do not see any record of a pending prescription for you.

Amy: (Losing patience. I am ordinarily a very patient person.) The doctor sent the prescriptions out twice. The first time was early last week, the second time a couple of days ago. I'm not sure what else I can do. I have to have this medicine by Tuesday. It's kind of a life or death sort of situation. (By this time I felt entitled to ramp up the personal drama a notch or two. Tears would come next.) I will try calling TUFTS again.

CURASCRIPTS: Don't worry Maam. We will sort this out. Worst case, we will have to implement a one-time override that will allow you to pick up your prescription at your local pharmacy.

Amy: (Overly grateful). Thank you so much for your help. Would you mind telling me your name so I can contact you again should I run into any further problems?

CURASCRIPS:  Of course, it's Chanel. Here is my extension number. Please call me anytime time. Best of luck to you.

Amy calls TUFTS: Can I speak with Sue?

TUFTS: Sue? We have no Sue at this number.

Amy: (Repeats her sad story for the 10th time to new stranger.)

TUFTS: Hmmm. Seems we have the prescription. The only problem is that there is not enough time for CURASCRIPTS to mail out the medicine so that you receive it in time to administer it. I'll call CURASCRIPTS and get back to you.

Amy: (Not as grateful. Beginning to feel more vengeful.) Great. Can you please give me your name and extension number. Are you planning to quit your job in the next week or so, or will I be able to reach you at this number. I would prefer not to have to retell this whole boring story for the 15th time to another stranger.

TUFTS: Certainly. My name is Michael. And we will fix this. Don't you worry Maam.

Friday, March 4, 4:30 PM

Amy calls CURASCRIPTS. Dials Chanel's extension.

CURASCRIPTS: Recorded message: This extension is no longer active. Please dial blah, blah, blah to speak with an operator.

Amy dials blah, blah, blah. Wades through 7 different electronic steps to reach a live operator. Tells the sad tale for the 15th time.

CURASCRIPTS: Well, it looks like we will need to implement a one-time override. Tell me the name of your pharmacy...

Friday, March 4, 6:00 PM:

Amy calls CVS. Can you tell me the status of my prescription.

CVS: What prescription. We don't have any prescription.

Amy: I give up. I suppose I would rather die of pneumonia than cancer.

CVS: Don't worry maam. We'll figure this out.

Amy: I doubt it.

Saturday, March 5, 9:00 AM (at least CVS works on the weekends.)

CVS: Your prescription is ready for pick up.

No major infections this week.

Tuesday, March 15, (8 days before I need the shot)

I thought it might help the process to initiate the dialogue earlier with the trio of brain surgeons that collectively have been so helpful in making sure I have nothing to worry about this round. Might as well stop bugging the actual physicians since to alienate them could also be life threatening. I'll start with my buddies at TUFTS who, after all promise, "No one does more to keep you healthy." If only they had a similar ambition for keeping you alive.

Amy: Is Michael there? (Hoping for a miracle)

TUFTS: Hello, this is Michael.

Amy (recovering from the shock of a logical beginning to the day's work.): Hi Michael. I haven't heard anything about my next Neulasta prescription which I need before the weekend.

Michael: Let me review the notes on this. (Twenty minutes later.) Hmmm. looks like Tufts has a 14-day limit on refills for this drug.

Amy: Well that makes sense. I only need it every 14 days.

Michael: Let me see what's going on. I will call you later.

Thursday, March17 (4 business days before I will need the next shot)

No word from  Michael. Just for fun I decide to call CURASCRIPTS To learn what they have to contribute to this comedy.

Amy: Can you tell me the status of my prescription?

CURASCRIPTS: We just filled that prescription.

Amy: I know. I am calling about the next one. The one that should already be in the mail so that I have it by next Monday.

CURASCRIPTS: Hmmmmmm. Let me review the records.  (Twenty-five minutes later.) It looks like we have the prescription, but it isn't signed by your physician. That may be a problem.

Amy: You're kidding me. Should I call the doctor?

CURASCRIPTS: Oh no. Don't worry Maam. We will handle it from our end. You should be all set before the end of the week.

Amy: I think about asking for this guy's name, but then decide it makes no difference. Okay. Thank you very much. Please keep in mind that this prescription isn't for cosmetic purposes. If I don't take it, my health is severely compromised...(couple of fake sobs.)

CURASCRIPTS: Never you mind; we will make sure you have it. You take care now.

Friday, March 18, 4:00 PM - 2 business days prior to when I need to take the drug

No sign of the drug. First call of the day will be TUFTS! Haven't spoken to them in a while. Might be nice to catch up.

Amy: Is Michael there?

TUFTS: Hi Amy. Michael here. How's it going? The kids and the hubby doing well? You feeling good I trust?. Nice to have a little spring in the air!

Amy: (Hearing his officious, high-pitched voice, I think...shut up you idiot. You are not my friend. You are my enemy who wants me to die from some horrible infection as quickly as possible to eliminate the expensive threat to your quarterly financial reports.) Hello. Can you tell me why I have not received the next Neulasta shot that I have to take on Tuesday?

Michael: Hmmmmmmmm. Let me just review the notes. (Thirty minutes later.) (Sounding very worried.) Well... it appears that Tufts has a 14-day refill limit on this drug which does not provide Curascripts with enough time to mail it to you. Looks like we will have to implement a second, one-time override.

Amy:  (Thinking, what a brilliant system with terrific, and well-named safety nets built in.) (Patience gone.)

Okay, so what you're telling me is this:  Tufts has a policy to ensure the careful distribution of this very expensive drug. Its rules for filling a prescription for this drug are as follows: (1)The drug may only be provided through a mail order company. (2) The refill period for this drug may not exceed 14 days. I've got news for you, reality has rules too: (1) Sending something through the mail may require several days. (2) 14 days - several days = a number less then 14 days. While I grant that Tufts rules are very well suited to the purpose of achieving the policy objective of controlling distribution of the drug, they effectively eliminate the actual distribution of the drug which may fly in the face of your mission  to keep your members healthy.  Listen, (a bit louder now as the absurdity lodges itself in my mind) I don't really care what you have to do. I need the drug by Tuesday. It might also be helpful if you could tell me what I should do to get the next two refills that I will need for this drug. Or does the system rely on a week filled with hundreds of phone calls, thousands of pages of documentation and pints of tears so that I can receive the third, one-time override that will allow me to pick up the drug at my local pharmacy???!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!.

March 18:00, 6:00 PM

CVS: Your prescription is ready for pick up. (Thank God for CVS.)

March 23: (13 Days before I need the shot.)

Having had a few vacation days from my new vocation of obtaining prescription drugs, I decide I can handle another conversation with the most recently abused member of my all-star team of  providers. Michael at Tufts.

Amy: Just wondering what the week holds for fighting with you guys to get my prescription that I will need following my next two infusions.

TUFTS (Michael): Oh hello, Amy. I hope you received your prescription with no trouble. (No joke. He said that.)

Amy: (suppressing the desire to guffaw and curse.) I am wondering what the status is for the next injection which I will need by April 4.

Michael: Hmmmmm. Let me check the notes. (You guessed it...35 minutes later). It looks like we just filled this prescription.

Amy (prepared for this latest display of efficiency and efficacy on the part of her insurance provider.) Yeeessss, (I say slowly, patience quota restored) I knoooow that. I am interested in FUTURE injections as opposed to the ones that are already inside of me.

Michael:  Aahhh, I see. I will have to discuss this with my supervisor.

Amy: Lovely. You do that. What is your supervisor's name?

Michael: Nick

Monday, March 28 (8 days before I need the shot.)

No word from Michael or Nick at Tufts. Decide to reconnect with them.

Amy: Is Nick or Michael available?

Michael: O hello Amy (with notably less enthusiasm than in weeks past.)  I bet you are calling about your Neulasta prescription.

Amy: (Amazed at this guy's ability to connect the dots.) Yes. Last I heard you were going to check with your supervisor, Nick, about getting me the prescriptions in time. I asked to speak with either you or Nick.

Michael:  Yea, Nick can't really answer the phone. (!?) Now, let me review the notes...(okay, I'm done with that joke, which really isn't a joke).  Well it looks like Nick is calling Curascripts and Jane (whoever that is) is working with Cecelia (whoever that is) at Curascripts , but Jane is out of the office. They are working on resetting the dispensing limit so it should work out fine this time. You should receive the prescription in the mail before the weekend.

Amy: (Having difficulty shaking images that might explain Nick's  inability to answer the telephone.) When will Jane be back.

Michael: Oh, don't worry about Jane. She'll be back in plenty of time.

Amy: Great. If I don't receive anything by Friday, I will call again.

Thursday, March 31, 2:00 PM

Phone rings!

Amy: Hello

CURASCRIPTS: Hello this is Curascripts I am calling to confirm your receipt of your prescription.

Amy: I have not received my prescription.

CURACRIPTS: Well you should get it in the mail by tomorrow.

Amy: Thanks. What do I do if I don't get it?

CURASCRIPTS: Call your health insurance provider.

Thursday, March 31, 3:00 PM

Phone rings!

Amy: Hello?

TUFTS: Hi Amy this is Michael. (Triumphantly) Your prescription is ready to be picked up at the pharmacy!

Amy: WHAT?????????????!!!!!!!!!!!!!!!!!!!!!!!!!!! I just received a call from CURASCRIPTS an hour ago telling me that the prescription was in the mail and that I should receive it by tomorrow! (Suspiciouly) Did Jane ever get back?

TUFTS: (Not as long a pause as the notes should merit.) Okay. You are RIGHT! Curascripts will be mailing the prescription. Everything is fine. It will all work out. Don't worry about a thing.

Amy: Well, in truth, I am a bit worried since you seem to think I should pick up the prescription while CURASCRIPTS is telling me it is in the mail. Who do I believe?

TUFTS: I am sure that the information you have from CURASCRIPTS is correct and that I am wrong! (he says with great cheer.)

Amy: Well, that is good to know(?) Thank you.

TUFTS: My pleasure. Have a very nice day.

Saturday, April 2

The holy grail is obtained through the mail.

[If you know people at TUFTS or CURASCRIPTS, or are planning to testify before Congress in support of health care reform, please feel free to distribute copies of this post!]