An Insurance Headache x2

Public Service Announcement: I do not recommend MDR Pharmacy for your fertility medication needs. I also do not recommend Security Health Plan (which is WI based- so you probably don't have that option anyway. Lucky you). Teachers are supposed to have "good" insurance. Well, I figured out a long time ago that was a big fat lie after reading so many people actually have some semblance of infertility covered. Yesterday, I got mad at our health insurance for two separate reasons.

I have been trying to get the pharmacy we have been using to submit our progesterone refill to our insurance company, since now the PIO is being used to sustain a PG, not for infertility use. After a lot of phone calls, they said they could not, but I needed to get my doctor to send my insurance a letter stating the medical necessity, and that they couldn't submit it to them, but I would have to ask my insurance for reimbursement. (still following me?) I realize now that MDR Pharmacy stinks and just didn't want to do the extra work. So I got my RE to send the letter, talked to a person at my insurance company, filled out the form and sent it in. Should have been a done deal, right? Well, two days ago, I got the form back stating that I needed to get the National Drug Codes from the pharmacy. First of all- I put the phone number on the form- why couldn't the insurance lady call and just get them? Second of all- are these really necessary?

So yesterday I called the pharmacy to get the NDC numbers. I got transfer to someone who wasn't available twice- then got fed up and googled National Drug Codes. Interestingly enough, you can actually look them up online. So I picked some for the drugs that I thought were close (I figured I should do all of them and see if we'd get reimbursed for more than just the PIO) and decided it probably wouldn't matter what the exact codes are anyway. Before I mailed the form, I called the pharmacy back just for kicks to try one last time(and to say that I had left a message three hours earlier and no one returned my call). This time the lady that answered gave me the NDC numbers to me right away (can you believe it?)... except for one. The PIO number (of course, the one I needed most). She said, "it doesn't have a NDC number." I told her that I searched online and other progesterone in oil medication had numbers so why doesn't mine have one? So she put me on hold, then came back and gave me a number. I said, "so let me get this straight- it doesn't have a number, but you just gave me one? Is this going to cause a problem when I submit it to my insurance?" She said no- but I put 0% stock in trusting her answer. Talk about frustrating. I remailed the form back to my insurance. Let's hope for the best- b/c we could really use getting back as much money as we can. Especially after what happened in the next paragraph.

Then, a little bit later (still stewing about the stupidity of the whole matter), I went out to get the mail from our mailbox and low and behold, we got a benefit claim form from my stupid insurance. Even though I am now PREGNANT and HIGH RISK, they still aren't going to cover any of the blood work or ultrasounds I have had including the first beta b/w and everything since then... because the clinic is out of our network. The beta, estradiol, and progesterone b/w alone is $400. I had that done four times since the transfer and one u/s (which I'm guessing will be almost $1000). We simply cannot afford paying over $2000 more after paying so much already. Especially since that crap would be covered for any normal PG person locally! I am supposed to have 2 more u/s and b/w done before being released to an OB. There is no way we can pay out of pocket for that either, and again, especially since if we were in our insurance network it would be covered. So we will be calling Monday morning to try to get this all figured out. If the clinic is going to have us pay for it since our insurance isn't covering it- I guess we have no choice but to go directly to an OB now and not continue with my RE until 12 weeks. Who knows when my next u/s will be if that is the case?

ARGH! This whole thing is so frustrating... especially so when I remember I had a co-worker who had weekly u/s until 12 weeks, just to "make her feel better" and her doctor coded them all high risk, even though she wasn't (she had one prior m/c and conceived without any medical assistance) so our insurance would pay for them. And I can't even get the initial b/w to confirm PG paid for, let alone our first u/s! SO NOT FAIR.