The IVF meds game, Part III. Oh, the Idiocy!

So Shasha, the call center person at David's health insurance company who told me that I could pay cash for my IVF meds and then submit the claim to David's insurance, was wrong.  I had wanted to do it this way because the cash price for the meds was significantly lower than the price they charge you if you give the pharmacy your insurance info.  I recently found out how huge the difference is.

But when I called to get the address to send my claim to, the new call center person wouldn't give me the address. She said that I'd done it all wrong and that I should have gone through certain specialty pharmacies to fill my prescriptions.

I told her that they'd better cover it because THEY told me how to handle it and what I could do.  What other source of information did I have?  I was trying to be a good consumer and I got them a better price.

When I faxed my claim info to this call center person, she started to understand why it was so important. The total for the drugs was $2,837. When non-IVF civilian types see those kinds of prescription costs -- well, let's just say they are not used to it.  So this other call center person totally took on my case. She worked and worked to get me a one time exception to cover my drugs even though I hadn't used their specialty pharmacies and gotten "pre-authorized" (i.e. my doctor hadn't sent them my records that stated why these drugs were needed.)

So she was so happy when she called me back because she thought she was delivering the best news ever. She told me she got it covered.  She couldn't hear my jaw drop on the other end of the line when she told me that she'd already gone ahead and paid the higher insurance-company rates for the drugs. They were charging us $5,004. That is nearly a $2,200 difference.  (My co-pay would be $1,100, and they would send me a check for about $1,600)

My call center person told me to phone the pharmacy to work out the details. She told me not to undo anything, because they had worked hard to get this through.

I thought back to 2.5 years ago and the same process and how much that drug charge and this one was going to count against my $10K lifetime maximum for infertility coverage. It was the exact same drugs in the exact same amounts. That would almost wipe out my maximum coverage, leaving nothing on David's insurance to pay for the doctor appointments, ultrasounds, procedures, etc. While MY company's insurance would pay for a lot -- 80 percent for in-network and 60 percent for out-of-network (the facilities for the IVF are all out of network) I saw myself getting totally wiped out financially. 

I woke up thinking about it the next day.  Insurance got me better prices -- contracted prices -- for doctors and procedures. But insurance got me WORSE prices for drugs. It didn't make sense.  But I knew I had to get the most bang for my buck.

So I called the pharmacy back and told them I wanted to pay the cash price and told them why. I told them I needed to save my other coverage for the rest of the IVF.  I told them I had not authorized my insurance company to pay those higher prices.  And so the pharmacy reversed it all and charged me cash again.

Then I got a call from my hero at the call center again who left me a voice mail telling me that NONE OF MY DRUGS went against my $10K lifetime maximum. I could have kept it on the insurance and it wouldn't have hurt my future coverage at all!

So I called the pharmacy back to try to undo it all again, but it was too late. What an idiot I am.  I was trying so hard to be smart. But it is very difficult to make smart decisions when you run up against brick walls trying to get any kind of information. You make the best decisions you can with the information you have at the time.

There is part of me that is wondering whether I should call that call center hero back and beg her to redo what she'd done before. And there is part of me that thinks I should just let it go. I don't want to deal with her being pissed at me. And I don't even know if she can redo it again. But it could mean an extra $1,600 to me and that's a lot of money. Sigh.

How can I even begin to get through the emotional roller coaster of the IVF when I can't even manage to get through the drug purchase?

Comments

[Aurelia]

Ouch, I'm so sorry. I asked somebody else before, and they weren't sure, but why is it we can't get cheap generic fertility drugs yet? They've been around for 20+ years right?
And no it's not that much cheaper up here in Canada either, I wish!