"Humana, I Want My Premarin!" Sequel

Last Thursday, after learning from my doctor’s office that my appeal had been denied, I called Humana to ask why.  After going through the usual menu tree, followed by the usual layer of people who don’t deal with this sort of thing, I finally got through to Humana Clinical Pharmacy Review, where a helpful young woman clarified the situation for me.  She said there were now three different transactions relating to my Premarin, each with its own number.  The first two had been denied but the third was still open.  I told her about the blog post I had written and she recommended faxing that, together with my doctor’s latest request, a cover letter referencing all three numbers, and any previous faxes or documents relating to the situation.  Later that day the doctor’s office sent all of this off.

On Thursday at 6pm I got a call from a young man at Humana.  He said that there had been a number of cases like mine and that most had been resolved in the patient’s favor.  The directive about not giving Premarin to women in their 60’s, he said, had actually originated with Medicare.  He hoped that my case would be settled within the next day or so.
 

Around noon on Friday I got a call from the same young man saying that Humana had accepted my appeal.  I now have a new number which I can use when the same situation comes up next year, which it will if I stay with Humana.  RightSource, the mail order drug branch of Humana, didn’t seem to have gotten the word about the recent decision so it took several long waits on “hold” before I actually got the pills ordered - but it’s done now.  From the time I first ordered the refill, the whole process had taken about a month.

On Saturday the mail included a largish wad of papers from Humana telling me that my appeal (the second one, evidently), had been denied and detailing the further appeal procedures that were open to me.  Why hadn’t they e-mailed all this to me when the decision was first made?

From Humana’s side of things, my doctor’s office could probably have laid a more solid foundation for the appeal, based on my current health and medical history.  It seems reasonable for the insurer to expect the doctor and/or patient to make a case for requesting a drug not in their formulary.  On the other hand, this doctor’s office has only known me for a couple of years and no one there would have time to dig through decades of my medical records.

What happens to patients who are not able to appeal a decision? Is someone with a painful or life-threatening condition nevertheless required to wait 72 hours for an “expedited appeal”? How many of them just give up and do without their medication?

Note to Medicare: Since you do not know me personally, nor have you read my medical history, I wish you would leave decisions relating to my health care to my doctor and me.  Please also read my blog post entitled "Statistics and the Twenty Year Rule."