Case #68056404

Decision:
The Appeal Committee has maintained Medica's denial of Ms. _insert my full name here_ request to waive the 20% coinsurance up to a maximum of $200 per refill, for her prescription of Betaseron.

Rational:
1. The Appeals Committee had determined that the change in prescription benefits that took place on July 1, 2006 was clearly outlined in the Certificate of Coverage, BPL#75295, Section G Specialty Prescription Drugs. Formulary specialty prescription drugs, such as Betaseron, are to be received from a designated specialty drug pharmacy and the member is responsible for a 20 percent coinsurance up to a maximum of $200 per prescription unit or refill.

2. The Appeals Committee understood that the benefit change has posed an economic hardship for _insert my full name here_. Unfortunately the Appeal Committee cannot change or amend the Certificate of Coverage.
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I love this. So under bullet number one because the change was CLEARLY outlined is suppose to mean something. To me now it's clearly outlined and is also clearly an example of bad policy.

The second bullet point is priceless. I love how they state it's "understood that the benefit change had posed an economic hardship"... they should have finished that sentence with "but we really don't care and we are lame"

What I find most interesting is that I had my appeal on Tuesday and on Wednesday I posted about it on my blog and today when I checked my site meter it showed up that someone from Medica actually read my blog. I am curious what that is all about. Maybe whoever from Medica has read this blog would care to comment?

Medica

My health insurance Medica has made a change in my policy. They placed my MS medicine on a list that they call a "Specialty Med List" and are now telling me I have to start paying $200 a month for my MS medicine that I have always paid (for the past four years) $11 a month for. I had a super fun meeting today with four Medica employees regarding this. Today was my "appeal". I was in the super fun meeting with the panel for 6 minutes. SIX! How much can you really accomplish in that time? Well, I'll tell you. Within that time I told them that I would appreciate it greatly if they would so kindly go back to doing what they always have been doing for the past four years. One woman looked at me and said "well you know this is in your insurance certificate of coverage" And I stated to her that yes, in fact, I was aware that this change it is now in my certificate of coverage and that I was also aware that this appeal is probably one of those rubber stamp deals where they all shake their heads, say they are sorry, but really there is nothing they can do to help me and then promptly deny my appeal. I told them that the problem I have is that Medica just made a change. Someone higher up at Medica decided that my medicine should now be put on a Specialty Med List and therefore I now have to pay $200 a month. Just like that. An arbitrary decision in which I believe another arbitrary decision could be made to (are you ready for this) CHANGE IT BACK! (I know, I know it's a mind blowing concept.)

I've been trying for the past few weeks to make some sense of this. You know to find the greater meaning in it all, because mostly it just feels like I am getting screwed with my pants on.

MS has changed my life and honestly in some pretty good ways. I never want to be thought of as a victim or disadvantaged because truly everyone has something. Everyone has their own personal battles in life, so I don't necessarily want to be looked upon as poor little Becky. Ever. But I would like some consideration from my insurance company that I am --in fact-- a human being and that it would be nice if they could start treating those whom they are in business to serve a little bit better. I find out on Friday if Medica will allow me to go back to the way things were. I am not holding my breath.

I was thinking about my super fun meeting there today before I met with the panel as I sat in the lobby of this insurance giant and looked around at the deep mahogany walls and the sparkling marble floors. I noted the lavish decorations that have been put in place for the holiday season. Dozens of poinsettia's, wreaths of garland tangled with ribbons and glitter. I looked at the thick glass top desk that housed two well dressed, perky girls who cheerfully greeted the folks as they entered the grand waiting area. I tried hard to think and figure out where I fit into this place. What was I really here to accomplish? I know that I've been worked into the actuaries equation. They know exactly how much I will cost them if I fight this change in policy. I've been reduced down to a number that will help them meet a better bottom line. They have figured out that my complaining, my requests for their time for an appeal, that it is still less expensive in the long run to make this policy change. They have probably figured that I'll just stop taking the medicine (which I currently have) and already in two months it's saved them $4000. This drags on longer and next month they will save another $2000. Someone is going to get a new boat at Medica for Christmas at my expense. Meanwhile, I sit and wonder if my MS will hold steady without the medicine. I gamble with my future because of Medica. I don't have an extra $200 a month to pay for the medicine. I just don't. I don't live extravagantly. I am the thrift store queen. I work hard and give back in the line of work I choose to do. A co-worker once said that a civil society is one that takes care of it's people. And I couldn't agree more. I still believe that and work towards that with the employment I choose, but I am beginning to see how those choices are probably making my life harder. I still don't know if I would choose another way. Sell my soul to work for Best Buy? Sure, but only if it's in their corporate giving department.

Today at the end of the super fun six minute meeting I made one last comment. I told the panel that I understood part of the problem they are faced with is making an exception for just me. I understood that they couldn't really do that just for me and I wanted them to know that I couldn't agree more. I want the policy changed back for everyone who's taking MS medicine. I want the "specialty med list" to go away. That this isn't a fight for me alone. That's what I realized today of the role I probably have. Our lives are always bigger than our own imagined personal discomforts. Medica's actuaries actually have made an error in assuming I was the ordinary, or average. I'll make more noise about this, even if I don't want to.. and I don't honestly. I don't want to show my vulnerable side to the world all the time, but in the words of a very special person, sometimes to win a fight you have to start a fight. Healthcare shouldn't be for the privileged and mostly it already is. I'll fight this fight with Medica and I might lose, but it won't be because I gave up or in. So that's why I post this here today. It's about pushing aside the idea that my privacy is more important.

In the past two months I've spoken with the Attorney Generals office, the Department of Health, the Department of Commerce, and just yesterday the Minnesota Disability Law office. I've talked to my executive director of my organization, my doctors, the pharmaceutical company that makes my medicine, my co-workers, my friends, my family, and now the general public by posting this here. I need to step outside what makes me feel uncomfortable and push harder at this already tender spot. I won't tell you that I haven't cried about this. It does make me feel sad and I think that is normal, but that shouldn't stop me from moving forward with what I think is right.

Spanks

I don't have enough space here to say all the things I have in my life to be thankful for. I bike commuted into work today and it was really hard. Round trip it's about 30 miles and about 14 times today on my ride in I wanted to not be riding in. So, doing the math on that it was nearly every mile I felt less than stellar. Every mile I tried to give myself a break and remind myself that it was the first day back, in the cold, and I should go easier on myself. My body and fitness felt ok, but I couldn't adjust to the cool weather and I had a little bit of a headwind, but I persevered and felt happy (at the end) that I stayed with it. I know the route well and I know all the places I could have picked up the bus, or called my brother and just called the whole thing off, but sometimes you just have to push through the uncomfortableness of it all. I wasn't miserable; I was just not feeling it today. I have the return trip yet tonight and hopefully I have enough lights to make my way safely.

What I did like about today was that I forgot I was on a bike. I realized I've moved to an entirely different level of comfort with my bike. My feet clip in and out of the pedals without much thought of doing so. I can be stretched out on that bike for an hour or so and not feel any soreness of sitting in the saddle or having no ache in my lower back or any burn in my quads. The uncomfortable part came only from my mind and sometimes that is the most difficult to push away. Your body can send you signals that it wants to quit and those signals are hard to deny. One can usual figure out pretty quick if the physical pain is serious or just an annoyance that won't do any harm if you keep going, however, when the mind gets derailed it's almost impossible (for me) to get back on track. Today I had to continuously refocus and remind myself that my body wasn't hurting, that I was just uncomfortable, and that it wouldn't last forever. That it was only an hour. That I should smile. That I should look around. That I should be thankful.

I arrived at work and I was tired, but I was happy. It made me realize the effort that I had made and that I worked and that I tried, even when I didn't want to. It made me even more thankful that my body still works for me and that the MS is still cutting me some slack. I am thankful for my health. I am thankful for those who surround me and love me, even with all my imperfections.

Have a safe holiday to those of you reading this.

Two weeks?

This is one of my favorite pics. Me (in blue with white helmet) talking to the locals in San Gimignano, Italy. Oh I miss being there...



Biking in the warm Tuscan sun. How come Piper and I look like we are suffering and my friend Pete is just smiling?

I haven't ridden my bike at all this week. Or this past weekend. Actually this past Sunday marked a week since I'd been in the saddle. And before that it was almost 2 weeks. I miss it.

I've been running more as the weather gets colder and trying to maintain some fitness that way, but I am having a hard time dressing in full winter gear getting out on my bike. I am not sure why as I normally don't mind the cold and actually do better in the cold than in the heat in regards to exercise. I think it mostly has to do with the fact that it's dark when I find I can ride these days and darkness makes it feel colder.

So, I'm a wuss.

No more I say! I am resolving here, right now, that starting next Monday (the 20th) to get back out there and just toughen myself up for winter. Acclimate, if you will. I will start being thankful and stop whining. Also I plan to stuff myself on Thanksgiving (I love all that food ) so I should probably start burning some of those calories now.

I miss this guy

A friend of mine yesterday (whom happens to be a Republican) accused me of voting strictly along party lines. Saying that I only vote on the side with the person who has DFL behind his or her name. I mostly agreed at first, but then realized that isn't entirely true. I support Jim Ramstad and he's a Republican, and I agonized about voting for Hatch. I wanted to vote for Hutchison, but when it came down to it, it was a race against Pawlenty and I wanted him gone. While Hatch wasn't my first choice he still out ranked Pawlenty and I had to throw my vote where it had the most pull. Instant Run-Off Voting will help with this problem in the future and maybe, just maybe we'll get someone back like Paul Wellstone, but probably not. He was a rare and special individual who was so important. I think for certain he'd want us to keep the good fight up. He's missed so much most days, but his absence seems so much more prominent during times like this, for the obvious reasons. The democrats won back the House in this election and I don't know if that means anything will change. Time will show us all. I'm convinced that it's not about doing it "better than the Republicans", but more the idea that we can just do better, period. Wellstone said it best. "We all do better when we all do better."

Vote! Vote! Vote!

Vote - November 7th, 2006 Volunteer! Be Involved! I plan to vote and volunteer and then I plan to drink while watching the results come in. Either it will turn into a celebration or the alcohol will be used as a way to dull the pain if things swing the wrong way.

tech tech technical difficulties

Ok, so my friend Sander from St. Louis said to me in an email yesterday and I quote:

"I was reading your blog. You better not stop writing stuff!"

and I pause. I have been getting email from folks telling me to keep writing, and I am surprised and unsure what to do. I don't like the online diary idea. I only opened this blog because I wanted to share my Europe bike ride with the great people who donated money to help me get there. So, I don't know what to do. Sander is pretty much right about everything, so I feel like I should listen to whatever he says I should do.

I think I'll try it for awhile and see how it goes. I just get busy. I am private. I tend to be wrong about most things. So with those three stellar facts, we'll see how long it takes until someone emails me pleading that I stop writing.