Impatient

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Impatient reader's dogged persistence wins Anthem drug approval

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Here's a happy tale of persistence rewarded. When I spoke to Impatient reader David Garden last month, he was getting samples of Cymbalta from his doctor, and carefully cutting them in half. He was threatening to fill his prescription of the drug – commonly prescribed for depression - through an illegal supplier in Canada.

It was all because he'd switched Anthem Blue Cross plans. He went from an employer-sponsored plan to one purchased on the Covered California exchange. He later learned that the new plan did not include Cymbalta, or its generic version, on its drug formulary.

Garden has a form of muscular dystrophy, and he takes the drug to alleviate the chronic neuropathic pain associated with his disease. Suddenly, a 90-day supply of the drug increased from a $25 co-pay to $512.77.

I reached out to Anthem spokesman Darrel Ng, and asked him how there could be a wide variation between drug formularies, even among Anthem health plans. At that time, he told me that covered drugs and benefits vary by policy.

"Large employers have a lot of latitude to decide what type of coverage they'll offer the employees," he said.

"The drug formulary on the exchange was based off of the drugs covered by the Kaiser small group plan. So it's very likely that there are drugs that are on an Anthem large group plan that aren't on the Anthem exchange plan."

But Garden refused to accept such explanations.

Through Anthem's exception process, he and his doctor asked the company to cover his prescription. He was denied, because the clinical reviewer determined the drug wasn't a medical necessity. Garden then wrote a letter to Anthem’s Department of Grievances and Appeals, asking it to reconsider the decision.

This week, he got good news: Following his appeal, Anthem approved coverage of his prescription for Cymbalta, for chronic pain associated with his muscular dystrophy.

Now, a 90-day supply will cost him $75, he said.

His advice to others who discover that the medications they rely on aren't covered by their insurance?

"Don't take 'no' for answer," he said. And: "Follow the appeal process through."

Have you fought your insurance company - and won? Tell us about it in the comments section below, or e-mail us at Impatient@scpr.org. Your experience could inform future reporting.

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