you know what else has a hole in the middle of it?

Dear TG Ape:

{Health Insurance Company [Money-Grubbing Wankers, Inc.]}’s pharmacy benefit manager continually review* medicines, products, and prices, to make sure the drugs that work well and are cost-effective become part of your prescription drug benefit [figure out if there’s anything we can avoid paying for]. As part of this effort, there are changes [we’ve cut some things from the list] that could [will] affect your current drug choices [needs].

As of July 1, 2015, your current drug(s) listed below will require a medical necessity prior to authorization in order to be covered by your prescription drug benefit. You will pay the full cost of the prescription without an approved medical necessity prior authorization…

*improper grammar copied directly from original letter

You know, this may not require any special TGA sauce (not withstanding a bit of paraphrasing) to show it for the steaming pile of poo that it is. But I haven’t had a good opportunity for a rant in a while, and there are some subtler points that I want to highlight, so I’m going to break out the soap box anyway.

This, in my opinion, is the gist of the letter:

Hey, you know those expensive meds you’ve been taking? We don’t think you really need it and we don’t feel like paying for them any more, so we’ll only cover the cheap ones that don’t work as well.

Granted, one of my medications is extremely, outrageously expensive. It’s an extended release formulation of a far cheaper medicine for which there are generics, which has, as you might imagine, driven down the price (and demand for) the on-label version. The extended release version is exponentially more expensive, and exorbitantly so, considering the fact that extended-release technology has been around for as long as it has. But that’s not my fault; blame the pharmaceutical company.

However, rather than pressuring the pharmaceutical company about the price, the insurance company is just dumping the cost off onto patients. Worse, it is insinuating that it is the fault of those patients that this is being done, as though we were soaking the insurance company for more expensive medications than we actually “need,” although a justification for this line of reasoning fails to present itself even to my agile imagination.

You know what I “need”? I “need” to sleep for more than four hours (or less) a night. And without this medication, I don’t, because of pain. If it weren’t for this medication, I would have had to have been hospitalized by now (which, by the way, would cost even more than the inflated price of the medication that keeps that from happening). Which seems like a pretty good definition of medical necessity to me.

But now, I have to get “prior authorization,” which means that the doctor’s office has to patch a phone call to the insurance company to reassure them that the medication my doctor prescribed is medically necessary.

That is so ridiculous I’m going to write it again. Reassure them that the medication my doctor prescribed is medically necessary. Because, you know, doctors don’t actually consider whether drugs are medically necessary before prescribing them unless the insurance company forces them to.


This “prior authorization” business is nothing more than a cost-cutting measure, removing some benefits from the balance sheet by making patients jump through extra hoops to get them, because the insurance company knows there are a number of patients who won’t, or can’t, make the extra effort.

But I am not one of those patients. I am more than happy to trot this letter into my surgeon’s office and let his medical staff, who, believe me, you do not want to be on the wrong side of, call up the insurance company and tell them exactly what they think of this bulls**t.

Point being, of course, that I shouldn’t have to, and that placing this burden on people who are already health-compromised is particularly disgusting. Why not just be up front about it? The drug company charges too much for this and we don’t want to pay it any more.  I wouldn’t like that letter, but at least it wouldn’t insult my intelligence.

But don’t pass your dirty work off on me and pretend like you’re doing me a favor. I paid exorbitant sums of money for health insurance a decade and a half before I actually needed the coverage. Now that I do, you vampires will just have to deal. This is why you exist. Get over it, already.

About C. M. Condo

I am a late-diagnosed, high-functioning autistic living with chronic pain. I started this blog in March of 2014 as a way to try to process what was happening to me. It is my hope that by sharing it with you, we can both gain something, or at least learn something, from my experience.
This entry was posted in Aspect III and tagged , , , . Bookmark the permalink.

2 Responses to you know what else has a hole in the middle of it?

  1. christellsit says:

    Reblogged this on whatnoreally and commented:
    Such has been my experience as well and, no doubt, many of yours as well.
    What can we do about this? Ideas?


  2. christellsit says:

    Effing YES,YES,YES!!!


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