In August of 2016 I was at my optometrist’s office for an annual eye health exam. The doctor was concerned about micro-hemorrhaging that she noticed in the back of both of my eyes. She recommended that I visit my general practitioner as she suspected there was something systemic going on with me, perhaps diabetes or an autoimmune disorder. My GP took a blood panel, did a physical exam and said she’d find an eye specialist for me. I was shocked to receive a call later that day from my doctor telling me that I had an extremely elevated white blood cell count and she was sending me to a cancer center!
At the cancer center appointment I learned that my diagnosis was chronic myeloid leukemia. It’s a fairly slow growing leukemia in the blood forming cells of the bone marrow, but can change into an acute fast growing leukemia that’s hard to treat. Fortunately, there is an oral targeted treatment for this cancer. I began treatment with the medication and a regular schedule of lab work to monitor the incidence of the cancer cells. The medication was provided to me free of charge by the manufacturer of the name brand version. I qualified due to meeting the income guidelines and having limited prescription drug coverage on a very high deductible policy. Thankfully, the medication worked and I remain in remission while on the medication.
My husband and I are self-employed and it became obvious that we couldn’t continue on a high deductible plan because we were always having to pay for the expensive lab work and hematologist appointments.
At that point we enlisted the help of our adult daughter who works as an insurance and benefits counselor at a non-profit in the Twin Cities. She assisted us with a spreadsheet comparing plans on the MNSure Marketplace. We learned we could be on different plans. My husband stayed high deductible and I went on a gold plan that would cover my labs and hematology appointments, and my medication at a $25 copay monthly.
We read the policy and drug formulary carefully and called the insurance provider to make sure we understood the charges correctly.
They confirmed.
When it came time to call in my first prescription of 2023 the representative at the specialty pharmacy informed me that I’d have to pay my deductible and 50% co-insurance for my medication. I notified my daughter who began trying to reach different reps at my specialty pharmacy and benefit services to clear this up.
We ended up getting 3 different answers for the cost of my medication. The cash price for this oncology med without insurance is $4700/month. I’d budgeted carefully for $25/month copay with my higher premiums on a gold plan. While we were trying to solve this problem, I resorted to purchasing my medication with cash at an online pharmacy for 60 days at $40/month.
My daughter’s workplace legal representative referred us to Cancer Legal Care. I was contacted by Erin Hartung. Erin went right to work on my behalf asking for my story and responding with a plan. She suggested I write a letter of complaint to the Minnesota Department of Commerce while she wrote a letter to the administration of my health insurance company. Erin was responsive, friendly, professional and reassuring.
I was so relieved to have someone with legal expertise in my corner.
In five weeks time I received a call from my insurance company telling me that we’d read and understood my health plan correctly. My medication was supposed to be a $25 monthly copay.
The specialty pharmacy managers were incorrectly charging oncology patients.
This representative told me that any incorrect past claims of mine would be corrected and that the company would review other oncology patients to look for errors in their medication charges, as well.
So, not only did CLC and Erin help me, they also helped other cancer patients. I would never have been able to reach the right people on my own.
I am so grateful to Erin and CLC for helping me to get the coverage that I’d purchased for my lifesaving medication.
Laura
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Erin from CLC wants to be sure to add that this great result was possible in large part because of Laura's excellent record keeping and tenacity.
The impact of our work together with Laura on this matter is threefold:
1. Laura is getting the full value of the higher coverage level health plan that she is paying for, including a lower out-of-pocket cost than she was able to get through the discount pharmacy.
2. An internal system error within a major health insurance company was identified, is being corrected for future claims, and will retroactively correct past claims of other members of the plan.
3. Laura's unfortunate and frustrating situation, and her desire to address it, was recognized and supported, and ultimately helped others facing the same difficulties.
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