Yup, I have been a bureaucrat. Maybe not in the sense that you are thinking. As a school administrator, I have been called far worse than a bureaucrat, but there have been those who have thought that I was the person who stopped things from happening. I have never felt that I was a bad person or one who spent his waking hours figuring out how I might screw citizens out of their rightful requests. I am sure that there are still some community people in places where I was in charge, who feel that I was a stone wall of bureaucracy.
May I tell you that I could never compare to the professional bureaucrat, whose modus operandi is to stop anything from happening. I ran into a few of those yesterday in my search to find a way not to pay a gigantic amount of money for a medication.
Last year, I was hit with a bout of bechuana tummy (see Grahame Greene). After a sojourn with three gastroenterologists, I happened on a doctor who was so frank with me that he admitted he had no idea what was wrong with me. He discounted acid reflux, irritable bowel (a weird name for a disease) and Crone’s disease (since I wasn’t a crone, I could not have had it). In his final moments with me he said,” I am giving you an anti-spasmodic for your peristaltic rush and I want you to go gluten free.
Since I had no idea what he was talking about, I left the office wondering about the state of medicine in the United States. I went to the pharmacy to pick up my medication and began a regimen of gluten free life.
Would you believe that it worked? For the past year and one half, my tummy has been normal so that I can concentrate on all my other ailments. However, I was bothered by the fact that my medication was not covered by my prescription plan. I really never thought about it until I would have to pay for it at the pharmacy. I do know that there are certain more serious meds that cost $10 a pill (not Viagra) and that I was being petty and unconcerned about my stomach. So, I paid it and asked the pharmacist each time, why my insurance would not cover it.
Eventually, the question seemed to bore the pharmacist and I needed to know more than what she was telling me. I had heard of the word formulary. It is a list of acceptable medications that would be covered by insurance and medicare part D. You young folks will learn about these things later in life. I finally got up the courage to call my medigap insurance company. That’s the company that fills in the gaps that medicare won’t cover.
They are really pretty good and don’t ever bother me. I get scads of papers from them which I place in the garbage just above the cat poop (and that’s a bunch, we have three cats). So, I ventured a phone call to them. After an interminable wait, I was told that they really did not handle prescriptions, but they had farmed it out to a company called Optum Rx. I had never heard of them. I was aware that there had been, in the past, a company called Prescription Solutions (a solid name if I‘ve ever heard one). So, I called Optum Rx and after a time got a rough sounding voice asking me, at least, 12 questions about my identity and my family background.
Finally, I was able to insert my question about why my medication wasn’t covered. The voice said, “Let me do some research and I will be back to you in a moment.” The moment lasted about fifteen minutes, with intermittent questions of whether I was still alive. The final answer was that the medication was not in the formulary. As to why it was not, he did not know. He suggested that I call Medicare Part D and ask them.
I did call Medicare Part D after spending about 30 minutes trying to get their phone number. I got a pleasant enough woman from Jacksonville, Florida who eventually told me that the medication wasn’t covered because it was not in the formulary. I tried to elicit why it was not in the formulary. She really did not know, as did her supervisor. She told me to call Optum Rx and ask them whether there were any errors on the request for the medication.
So, after about 3 hours, I was back to Optum Rx. There, I got some answers. A young woman told me that the doctor who had prescribed the medication had made a mistake in the diagnosis and that his identification number could not be found in the system. I sure wished that I was told that when I first started on my journey.
So, I was back with my pharmacist, who is a person with infinite patience. She took all my information and told me that she would run my prescription through using good doctor numbers. When I returned a few hours later, she told me that it was not the numbers that were incorrect and that she used other numbers to see if they went through and they did not.
I asked her about comparable medications, which she then tried to no avail. I was now at the end of my journey, or so I thought. The pharmacist then told me to go back to my Gastroenterologist and get a new prescription and that would determine whether there was any chance to get my meds through Part D.
Fortunately, the doctor was just a few blocks away. The receptionist was great and I got a prescription in a few minutes.
I brought the prescription back to the pharmacy (I know this is boring) and was told that I had to have a diagnosis code and a wet signature. Further we were not going to submit this under Part D, but Part B. If you have lost me at this point, think about how it all struck me. I went back to the doctor’s office. The nice receptionist was not as nice as before. I gave her the prescription she had given me and told me to check back on Tuesday when the doctor was in. I await that moment.
Nice thing about going through all of this, it now makes me an expert on these things. So, if you are having a problem getting your own meds reimbursed, for heaven’s sake DON’T CALL ME.