Aetna has denied the presciption Tiara needs and I am crazy mad!

If you follow me on Facebook you know I was a basket case on Christmas Eve because our health insurance decided Tiara didn’t need 4 pills of Vimpat each day, but only 2, so they denied the pre-authorization and I was unable to get her medicine.   Why even have health insurance? 

Vimpat is one of her 5 seizure medications.  She  needs her medicine so much that if she were to miss a dose you might have a status seizure.  As  a result the last time she couldn’t keep her meds down because of the stomach flu, her doctor instructed us to drive straight to the hospital, anticipating the worst.  There is no messing around with Tiara’s medications, she must have every single one of them at 8:30 am and 8:30 pm every day of her life.

I had been working on for getting this approved for a week and when I found out on Christmas Eve it was denied, I went insane.  I literally lost my cool and screamed profanities at the poor Aetna lady even though it wasn’t her fault, I couldn’t control myself.  I was especially upset because they had been lying to me for 2 days.  The claim was denied on Friday at 2:17 p.m. and I called Friday after that time and Monday and it wasn’t until Monday at noon that a representative finally admitted it had already been denied.  I guess they felt so bad they had been avoiding telling me the truth.  On Friday, one representative kept apologizing and almost sounded like she was going to cry as I explained Tiara’s history to her.  I guess she didn’t have the heart to tell me Aetna could care less about Tiara and her daily seizures.

Aetna has denied Tiara the medication she needs and I'm crazy mad!

I was at my wits end and knew I only had 5 more days of medicine left but then Tiara was admitted to the hospital and the little problem was solved.  The hospital provided her with the Vimpat so that inpatient visit gave us an 8 day reprieve.  During the hospital stay, I called Aetna twice, the pharmacist, her neurologist and sent 2 emails to her neurologist.  Do you think anything got accomplished?  Nope, once again nothing!

At the recommendation of several people, Lou contacted the controller at his work, who is responsible for dealing with the insurance agent and explained Aetna’s refusal to provide the medication.  He requested they pass on this information to the agent and see if there was anything the insurance agent could do.  We tried all avenues but still nothing.

I woke up today, counted the pills and realized her last dose would be Friday morning and she wasn’t eligible for a refill until January 16 so I knew I had to get rude and mean today.  I mean why can’t my nice emails and calls get stuff done?  Why do I have to go hard core and start threatening people?  I hate it!  I also still hate Aetna.

This morning I sent a rather forceful email to her neurologist explaining that she needed to call this specific number and request a phone conference with a doctor at Aetna to discuss the medication.  I had been told from the controller at Lou’s work that a peer to peer conference could easily occur between the doctors if Tiara’s doctor just took the time to make the call.  Ha, Ha.  Well, after the strongly worded email, I received a response from her neurologist.

She finally took the time to call Aetna but guess what, Aetna gave her the same run around they have been giving me.  This woman is an epileptologist.  She travels around the world learning and teaching about epilepsy and yet when she called Aetna she was hung up on, sent to voice mail, and put on hold for over an hour.   She requested 3 different times to speak with a peer (Aetna doctor on staff) but was denied every time.  She was so frustrated and admitted to me there was nothing more she could do.  She suggested I take Tiara to the hospital if they refuse to give her the medication by Friday.  How on any level is this allowed or right?

To top off this whole wonderful day with Aetna, I took Tabitha to a doctor appointment this afternoon and went to the pharmacy with 2 prescriptions.  The pharmacist informed us that the first one for allergies required a pre-authorization and the second one wasn’t a covered medication so we could pay $58.00 out of pocket.  Fine we will use a different allergy pill and I guess I am forced to just pay out of pocket.   So hating them more at this point.

Oh, and the best yet, I forgot to mention that earlier today I received 2 bills from Quest labs.  One for 739$ and one for $687.  Have you ever heard of such a huge bill for blood work?  I have not, so I called the lab thinking it was a mistake and they claimed our insurance hadn’t paid any portion and it wasn’t a mistake.  I then called Aetna again and they claimed we have a $750 deductible per person for any in network lab or x-ray work.  What the hell?  Why are we paying $1600 a month in premiums through a large group plan?  What are we paying for?  I have avoided using HMO plans the past 10 years because I couldn’t handle dealing with all this crap and was always fearful Tiara wouldn’t get her medication and all the services she needed so we pay more, in an effort to avoid all of this stress.  Now, I am broke, and stressed because they refuse to live up to their end of the contract.

So I ask the question:  Is Aetna an insurance company or are they Tiara’s health care provider?  Seems like they are practicing medicine without actually examining the patient.  Thinking this is illegal? This has got to stop!  This system is so screwed up and I am so frustrated and if you tell me Obama-care can fix this, you are insane.  I think Tiara would already be dead if we had Obama -care, but then again that is my own opinion.

What I think is that our whole country needs to get their priorities in line. 

We need to care more about people and less about money and until that happens nothing will change.  Guessing that will never happen in my lifetime so now I have to make a plan for tomorrow.  Any great ideas, please pass them along.  If all else fails, there is always the press. 


xoxo tiffani

tiffani goff at home

Views: 12

Tags: health, insurance, issues, medical


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