Patients and Physicians Speak Out

Being a type 1 diabetic, I need insulin pumps and glucose testing supplies. I have been using Omnipod Classics for almost 10 years. The company that I now work for had a health insurance option, HealthNet of Oregon. They immediately rejected my Omnipods because they weren't a necessity. I started paying out of pocket for Omnipod Classics and Dexcom G5 continuous glucose monitoring (CGM) system. I eventually dropped the Dexcom and started testing manually, because I could not afford $3,000 for a 90-day supply. 

I ended up spending over $10,000 on credit cards trying to keep my Omnipod supply. In late 2022, I found out my Omnipod Classics were being phased out, so I needed to upgrade. I tried for a whole year to get them approved. My doctor’s office goes through every hoop to send preauthorization paperwork only to have it denied with the reason being ‘not enough info.’ 

My doctor’s office sent copies of emails with lengthy explanations and records proving the necessity. It wasn't until Healthnet appointed me a case worker that I got a year-long override to have Omnipod 5 and Dexcom G6 CGM system. Now, in 2024, I am still fighting to be reimbursed for the out-of-pocket expenses for medications that should've been approved from the start.

I was denied a simple lidocaine cream because I could buy it over the counter. Now, I couldn’t buy the same strength over the counter, and nothing worked but this prescribed cream. What was once covered easily became a prior authorization medication. [It’s] super frustrating for such a simple prescription – I can’t even imagine having to wait for something like a cancer medication or insulin because of a prior authorization issue. Obviously, if your doctor is prescribing it, then they feel it is the best medication for you. The insurance company shouldn’t dictate what’s best for patients — they aren’t MDs.

I was approved for my medication and took it for 6 months. It lowered my blood pressure, A1C (hemoglobin) and hormones, and helped tremendously with my arthritis and joint pain. When it came time to renew my prior authorization, my insurance suddenly denied my doctor's request stating that they needed more records. These were provided and a peer-to-peer was done; however, they keep denying my doctor's appeals. 

Meanwhile, I’ve been without my medication for a month now. I can barely move from the pain from arthritis. I’m feeling a lot worse now and I cannot afford the out-of-pocket expense for my meds as I am the primary breadwinner, taking care of a 100% disabled veteran husband and our disabled daughter who has autism spectrum disorder.

Prior authorization for proper medical equipment and subsequent denials is what led to my mother's early demise and significantly lowered her quality of life. Now, I am also receiving similar prior authorization issues that are making it difficult for me to get medication. If you're on the same drug and the doctor increases the dose, why is there a prior authorization needed when they already have a prior authorization for the drug? This is absurd and is just an attempt to make it so difficult for the doctor, the pharmacy with excessive paperwork and the patient to get proper care.

I have Medicaid, and I was denied a medication with preauthorization from a doctor. I have had migraines for the past 30 years, and she gave me 75 milligrams of Nurtec ODT (rimegepant). You take one pill every other day to prevent migraines. When I was taking them, for the first time in 30 years, I didn’t have a migraine. 

I suffer from them [migraines] probably about 17 to 20 days a month. They make me sick, as in vomiting, and I actually have to go to a dark room to lie down. It hurts so bad, and it also makes my eyes blurry. I understand it isn't a cheap medication, but it actually works. You don't know how that feels – to suffer from migraines and not have any [medication]. Then your insurance company denies your medicine that you know works and you can't afford it. Just like the time when I had to take a thyroid medication, .075 micrograms of Levothyroxine, and was denied by Medicaid. Seriously. So, what, am I supposed to not just take my thyroid medication? Which I'm not because I can't afford $107.00 a month for it. But even with the Nurtec ODT, insurers are denying someone’s medication, which the doctor says helps tremendously and isn't a generic brand. I have taken everything else that Medicaid said I could have, and it didn’t work...

I've managed chronic, episodic migraines for 30 years. I've figured out tricks to complete work with a migraine when I wasn't able to take a sick day or reschedule something important and avoided narcotics. I worked through the pain, sometimes with a bandana tied tightly around my head, quietly slipped away to a bathroom to vomit, or gripped my desk so hard I broke off part of it. 

I usually end up in the ER 1 to 2 times per year due to breakthrough pain which medicine at home could not control after 8 to 14 hours. I visit headache specialists every 2 to 4 years to understand new options. I eat healthy, avoid alcohol, exercise and rest. Instead of it getting easier, preauthorization procedures have become repetitive busy work that ignores the fact that I and my care team are experts. 

My primary care doctor will no longer fill out the preauthorization paperwork, and I don't blame him. He does not have the staff to fill out inane paperwork or wait on hold to satisfy a checklist so CEOs can get a bonus of $20 million per year on a salary of $1.5 million. The 2 to 4 months wait for a specialist to have the same conversation over and over ignores my valuable time, which could be better spent using a medication that's been proven effective several times, vs. others that are less effective with more side effects which cause me to be unable to poop for days at a time... Caremark should know they're doing their part to keep health care complicated, expensive, ineffective and literally constipated, despite their claims to the contrary.