For those of us with chronic health issues, there are many hurdles to jump over that others simply don’t face. We are often put in situations where success seems impossible to achieve. In my experience, the navigation of insurance company policies is one of those situations. The rules can be so contradictory that they seem purposefully designed to foil our best attempts at success. These situations are joking referred to as “catch-22’s.”
I’ve always appreciated Joseph Heller’s character Yossarian, found in his novel Catch-22. Like him, I am Assyrian. I have also had people almost kill me. But, they weren’t specifically targeting me. They just had no idea how to treat my disease, and their ignorance almost cost me my life.
“That’s some catch, that Catch-22.”
While reading the book, I laughed out loud when I came across the passage below. A pilot named Orr faces almost certain death if he flies more missions. The only way out is for him to claim insanity. However, by claiming insanity, he proves that he is sane. If he is sane, he would have to fly the missions. The author captures the dilemma best.
“There was only one catch and that was Catch-22, which specified that a concern for one’s safety in the face of dangers that were real and immediate was the process of a rational mind. Orr was crazy and could be grounded. All he had to do was ask; and as soon as he did, he would no longer be crazy and would have to fly more missions. Orr would be crazy to fly more missions and sane if he didn’t, but if he was sane he had to fly them. If he flew them he was crazy and didn’t have to; but if he didn’t want to he was sane and had to. Yossarian was moved very deeply by the absolute simplicity of this clause of Catch-22 and let out a respectful whistle.
“That’s some catch, that Catch-22,” he observed.
“It’s the best there is,” Doc Daneeka agreed.”
– Joseph Heller.
Pharmacy Benefits: Our Catch-22
In the chronic illness world, I have dealt with my own Catch-22. The pharmacy benefits on my health insurance reject all injectables on principle. I say they reject all injectables, but apparently insurance is willing to pay for some life-saving injection medicine but not others.
Do you require a life saving injection in the form of an epi-pen? Congrats. Pharmaceutical benefits will cover your injection because it’s life critical. Do you require a life saving injection in the form of insulin? Congrats. Pharmaceutical benefits will cover your injection because it’s life critical. Do you require the life saving injection in the form of Solu-Cortef? You’re out of luck. This life saving injection is not deemed life critical.
Do not fear! Although this prescription drug is not covered under pharmaceutical benefits, it is covered under medical benefits. All you have to do is find a pharmacy that has the capability to bill medical codes.
Bill to medical codes?
After many hours on the phone with multiple pharmacies, medical insurance agents, lots of googling, and chatting with others in a similar situation, I have reached the following Catch-22 conclusion:
- The prescription Solu-Cortef is covered by insurance, but only if the pharmacy can bill to medical codes.
- The only pharmacies that can bill to medical codes are specialty pharmacies.
- Solu-Cortef is considered a “retail drug,” and therefore specialty pharmacies do not carry it. They recommend I purchase the medicine from a retail pharmacy.
- The retail pharmacy cannot bill to medical codes.
- Therefore, my Solu-Cortef is not covered by insurance.
- HOWEVER, my Solu-Cortef IS covered by insurance, but only if the pharmacy can bill to medical codes…
Submit inadequate paperwork?
Now insurance did inform me that there is another option:
- I must collect all paperwork that the retail pharmacy gives me with information about the drug.
- It has already been determined that the paperwork that the pharmacy gives me does not contain enough information, and therefore the paperwork has already been rejected.
- I must hand write on the proper “J” code (that’s the medical billing code) on the paperwork that the pharmacy gave me, that insurance has already rejected.
- I must get my doctor to write a new script, not to give to the pharmacy, but to give to the insurance. This script must included my IDC-10 diagnosis code on it.
- The script needs to be sent in, along with the paperwork that insurance requires but has already rejected.
This appears to follow a similar logic as above. It’s another catch-22 loop. “You want this piece of paper to process the claim, but you have already stated that you cannot process this claim off of this piece of paper, and thus the claim has been rejected. Yet you want this piece of paper to process this claim…”
Well played insurance company. Well played.
What to do?
I cash pay, using a discount code that brings the price of the drug down from “This is so cost prohibitive we’re going to bankrupt you” to “This is just kind of expensive, but your life is worth it.” It’s not ideal, but it does keep me Clearly Alive.
Do you have a fun catch-22 logic experience with your chronic illness? I’d love to hear about it!