State panel helps customers challenge denied health coverage

What do you do when a prescription medication that once cost $15 a month now costs hundreds of dollars? Health care reform is supposed to eliminate many such issues. But that’s still almost two years away.

Meet Deanne Erickson, a breast cancer survivor from Federal Way who recently got a rude surprise at the pharmacy counter.

For about five years, she’s been taking a drug to keep what she calls her “estrogen-based” cancer away and paying about $15 a month at the pharmacy. Recently, she changed health insurance providers at work. “I went in to pick up my prescription and I was charged $283,” said Erickson.

Her new insurance provider, Premera Blue Cross, had decided her oral medication is a chemotherapy drug, covered as a medical benefit, not a pharmacy benefit.

“Which means that I have to hit my $2,000 deductible before my costs of this particular prescription go down,” Erickson was told.

Erickson insists she doesn’t have cancer and besides, she argues, the drug, Exemestane, is often provided as a prescription benefit for treating conditions other than cancer and thus subject to just a small co-pay.

Premera’s Eric Earling explained how the insurance provider covers the drug that Erickson has been taking.

“It’s currently being covered through a medical benefit with the exception of members that might be taking oral chemo for non-cancer conditions, in which case it’s being covered under a pharmacy benefit.”

But even though Erickson says she’s cancer-free, Premera considers Erickson a cancer patient.
Erickson says her doctors don’t consider her prescription drug a chemo drug. Premera says it is, so she doesn’t qualify for the exception.

Earling says in trying to adopt new rules mandated by the state legislature for the coverage of chemotherapy drugs, Premera experienced “unintended implementation issues” and is trying to “adapt as best as possible.”

Erickson challenged the decision on her coverage to Premera, which denied her appeal. So she asked the state Insurance Commissioner for help. Mike Kreidler says the state has set up a system to accept appeals in cases where patients claims are rejected by the health insurance company.

“And I strongly urge consumers, when they have a dispute with a health insurance company, to follow it up that way,” said Kreidler. “This isn’t your last answer, just because the company, in their own in-house review, said ‘No.'”

The state Health Department has established the extra appeals process. “You still have this opportunity to go through an independent review organization to give you an un-biased, third-party assessment as to whether you’re eligible for a particular benefit, or not,” said Kreidler.

Erickson has a letter from her doctor declaring that the medicine she is taking is not a chemotherapy drug and she thinks she has a case. But she’s not counting on it. “I think I’m going to end up paying for this thing until August.”

That’s when Earling says Premera will change its policy and provide prescription benefit coverage for Erickson’s drug, no matter what the definition of the drug or the customer’s condition. Sadly, for Erickson, that really won’t help her this year. By August, she figures she’ll have reached her $2,000 deductible.