Over The Counter

My health insurance company has decided that it will not cover the cost of a medication prescribed by my doctor. Here I was, thinking I had a bonafide medical condition that required actual treatment.
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My health insurance company has decided that it will not cover the cost of a medication prescribed by my doctor. Here I was, thinking I had a bonafide medical condition that required actual treatment. Imagine my surprise when I went to the pharmacy to pick up the medicine my Board-certified doctor prescribed only to find out that my insurance carrier does not agree with his medical advice.

"I'm confused," I said to the drug store associate. "I just came from the doctor," I explained. "He sent over a prescription. Did you get that prescription?"

Yes, the drug store associate nodded.

I asked if there was a problem with the prescription itself. Like maybe it was written in invisible ink, or cuneiform.

"We're very tech savvy here," the associate boasted. "Every order is submitted electronically, so we see it just as soon as the physician types it in."

"So you received my prescription, but you cannot fill it?" I asked, still unsure.

"Oh we can fill it," she said. "But your insurance won't pay for it. If you want, you can call your insurance company." The line of patrons behind me was beginning to coil. "If you can step to the side..."

I didn't want to step to the side. The side is where they stow people who did not bring the proper forms or who have disagreements with the management. I didn't have a disagreement. I had an infection.

I stepped to the side and called the toll free number on the back of my insurance card, and then followed the rat-in-the-maze instructions dictated to me by a robot. Policy number. ID number. Plan number. Group number. Date of service. Date of birth. Bra size.

Next to me, a demure woman pegged numbers on her cell phone screen with an acrylic nail that curved over like a talon. She mistyped, swore, and then descended into the frustration abyss, shrieking at her phone: "Representative! Representative!"

I got lucky. Someone named Megan came on the line and very sweetly offered her assistance by placing me on hold. I selected a bar of candy from the display shelf, peeled the paper wrapping back and nibbled while Frank Sinatra sang, in its entirety, "Fly Me to the Moon." My mouth was full of chocolate when Megan returned. "So I see that this medication is classified as a Tier Three Plan and is not available in generic form," she said.

I swallowed. "What does that mean?"

"It means," Megan said sweetly, "that you have to pay for it."

"But I have insurance."

"Yes you do. But your coverage applies only to generic medications."

"But you just said, this medication is not available in a generic," I challenged her. "So how can I buy something that does not exist?"

Megan held her ground. "You might ask your doctor to recommend something," she said.

"I did," I said. "He recommended this medication."

"This is not a medication that your plan covers, ma'am," Megan said.

In my experience, the use of the word ma'am signals an end to any previously charming exchange.

I softened my voice. "There must be some recourse for a situation like this. Can I speak with your supervisor?"

Megan, on our recorded line, had one more suggestion. "You could submit a Co-Pay Reduction Authorization Form," she added most helpfully. "Your doctor would have to contact our office to download the form." Once completed, she explained, the form would be reviewed and a determination made within 90 days.

"Will that work?" I asked. "Will they cover the drug?"

"Probably not."

She clicked off.

I leaned toward the drug store associate. "I'll just pay out of pocket for that medication," I said to her, holding out my wallet like alms for the poor.

"Take a seat over there," she said with a toss of her head. "And we'll get to that right away."

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