I was recently been diagnosed with ADHD. While this was a bit of surprise to me, it has not been to anyone else, which makes me wonder why no one SAID ANYTHING TO ME about it. But I digress.
I was prescribed non-stimulant medication first. After 2 months we upped the dose but it was apparent it wasn’t working, so last week my doctor prescribed something else.
And after some back and forth between my doctor’s office and my pharmacy my insurance denied coverage. So I called Wellmark Blue Cross Blue Shield to find out why. The reason? Wellmark doesn’t cover this drug as a first choice option for ADHD. They need proof that I’ve tried something else that didn’t work first.
Now maybe you think that’s a logical position to require something else (and cheaper I might add) first. The drug they are denying isn’t cheap even though it’s a generic. But if you were paying attention, you’ve already spotted the issue.
I’ve filled 3 prescriptions for the first medication. 2 for the lower dose and 1 for the higher dose. All of there were purchased at the same pharmacy, the pharmacy that has and always runs my insurance. So, how does Wellmark not have record of the 3 prescriptions they already covered? Why is the burden now on me and my doctor’s office to provide documentation that I tried something else first??
For what it’s worth, the very nice person at Wellmark I spoke with on Friday afternoon did do everything within his power to help me understand what the next steps were and all but admitted the system that issued the denial is flawed. I understand that he was limited in what he could say, but I felt heard and helped to extent that he could help.
But that doesn’t fix the problem. The good people at my clinic now have to waste their time this week filling out God knows how much paperwork when Wellmark already has everything they need but won’t look for it themselves because that information wasn’t submitted exactly they way someone (likely an AI bot) decided it needs it.
Make it make sense.