The State of Health Insurance for 2017 – is That Prescription Medically Necessary?

A lot has happened since my last blog….which was December 2016.  Lots of ‘new’ things have taken place so far in 2017 – a new President of the United States, a new health insurance as well as a new primary care physician for me, a new Superbowl champion (well, they’re not new to champions for Superbowl, but because it’s a new year, yes a new champion for 2017).  And nevermind my opinions regarding a couple of the above-stated ‘new’ things….some things are just better left unsaid.

I am still covered by the AHA (a/k/a/ Affordable Healthcare Act and/or Obamacare) with an insurance called Ambetter. At first I was a bit skeptical about having this insurance, thinking I would not get the same quality health care as previous insurances or whether I’d keep the same physicians, but so far, so good!  My monthly premium went down which is a plus for me – going from $251/month to now $94/month plus $20/month for dental!!!  Whoo hooo!! But the best part about this so far is the prescription medications.  Folks, you won’t believe how excited I am about this. money-1270332_1280

So in years’ past, I have been taking Crestor (rosuvastatin) for my high cholesterol. I have been tried on all of the other ‘statin’ medications used for high cholesterol and they have either not did the job of bringing the cholesterol levels down or there were awful side effects that I could not deal with, so Crestor has been the only one that has cut my cholesterol levels in half and with no side effects.  Problem was that Crestor/rosuvastatin was the most expensive medication I’ve ever had to purchase.  I have paid up to $185-200 for a 30-day supply of Crestor – and that was with using GoodRx (the free prescription-saving coupons available to use when purchasing prescription medications) as well as my insurance. Last week, though I had to go through some finagling through my new primary care – or what is called in the healthcare world as medical necessity – and through my new health insurance I am only paying $1 for the rosuvastatin!  Yep, I said $1, and that goes for all of my generic-named prescriptions I’ve been using.

A portion of medical necessity in short means this: Whether it’s a prescription medication, an x-ray/MRI or cancer treatment and beyond, one must get authorization from your physician, whether primary care or specialty physician to state that it is medically necessary for the use of that medication and/or procedure.  In my case, a prescription needed to be filled and the insurance would not pay for it (many medications are not being paid through the insurance company for 2017), so then you have to go through either your primary care physician or specialty physician and have them to authorize the use of that medication. Therefore, the battle begins between the insurance company, pharmaceutical companies and the physician making the order. The insurance company wanted to know WHY I could not use the other statin medications (in which they would pay for) and my primary care reviewed my medical history and clinical documentations and explained to them that ‘she was tried on all other previous statin medications and to no avail were they effective; therefore it is medically necessary for my patient to take the rosuvastatin.’ That’s all it took – a little bickering, an authorization by my physician and a signature – and so for now – for 2017’s health insurance – I can now pay only $1 for my generic medications!

This is why I blog folks, so that I can inform you about the challenges we have in healthcare/health insurance these days and be to become proactive – empower yourself in saving yourself money and time as well as remaining healthy. I cannot speak for all health insurances, but I believe this is true for a majority of the health insurance companies. Whenever your insurance company will NOT pay for a particular prescription medication or pay for medically necessary procedure, it doesn’t hurt to ask your primary care or your specialty physician to get them to authorize what may be medically necessary, whether a particular medication or a procedure by digging deeper into your medical history.

The repealing of Obamacare for 2017? I’m not worried about it this year. It’s in place for now and since there is no new replacement healthcare plan in place as we speak, it would take months to  repeal it.  Plus there are too many people – 20,000,000 to be exact – that would be affected by it, and I’m pretty confident 20,000,000 will go kicking and screaming to the White House to keep this from happening……We shall see!

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