Insurance issues -- any advice?

[axelrods]

Hello, All:

I'm having a lot of trouble getting Zofran refills approved by Unicare, and have been paying out of pocket for a 3 weeks already. Luckily my Dr. was extremely proactive and started me on meds immediately after only a couple of days of constant vomiting. I've now reduced my dosage to the minimum that keeps me from vomiting (much), though the nausea is often severe. I'm really feeling at a loss here. It's the only thing that has been keeping me able to function -- I'm sure you're all familiar with this. I tried both Reglan and Compazine first, and had unbearable side effects with both. The Zofran was like a miracle. I'm now 12 weeks and have actually gained a bit of weight as I should.

Unicare refused the initial application, then denied the appeal, and keep giving me a real runaround (claiming they didn't receive various faxes, giving no concrete reasons for denial other than "not medically necessary"). My Dr. sent them a letter -- perhaps it was too positive -- about how well I'm doing on the Zofran (maybe he should have emphasized that if I weren't taking it they would be paying for me to be on an IV...hard to get your Dr. to take dictation, no?)

Anyway, the last communication I got was that I have the right to an independent appeal by the State of CA, which I plan to do. Has anyone been through that? Any tips? I don't meet the income requirements for the GSK help, but paying out of pocket for Zofran is enough to break anyone's bank account.

Thanks,
Susie

[mrsbigdog]

Keep fighting. I didn't start having issues with my insurance co until around 35 weeks and my daughter was born at 37.5 weeks so I didn't have time to fight very long. Maybe someone else has more info about the state appeal but I certainly would continue fighting. In the mean time see if your dr can request some samples from the manufacturer. Mine told me it would take a couple of months but it wouldn't hurt to try.

Donna

[natacha]

My insurance only paid for 9 pills each month. I fought them initially and my Dr. did too, but I just didn't have the energy to fight them, and its too late now. If you can fight them, do it!

[Trubiedoos]

My Dr. sent them a letter -- perhaps it was too positive -- about how well I'm doing on the zofran (maybe he should have emphasized that if I weren't taking it they would be paying for me to be on an IV...hard to get your Dr. to take dictation, no?)

That would be my first step I think. Try having him submit paperwork about it's medical necessity based on the zofran's ability to keep you off of home IV's and hospital visits too. Mine literally states: patient with severe hyperemesis gravidarum, zofran avoids hospitalization. That letter and a convincing phone call gets me 60 pills a month (it used to be 15). My dr. treats me, and 3 others with the same insurance so I think he knew what he needed to say. Just TELL your dr. what to say and don't feel badly about it.