‘It makes me angry.’ Doctor prescribes her a medication, but health plan says no

Thousands of Floridians are encountering significant obstacles when attempting to fill prescriptions as health-insurance companies increasingly deny coverage for medications recommended by their doctors.

For some, the struggle has become a way of life. Marilyn Bach-Nuñez, a 71-year-old retired advocate in Sunrise, cares for her daughter, Joy, who has a rare genetic condition that causes chronic pain. Bach-Nuñez, who has COPD and rheumatoid arthritis, said she has had to fight her health-insurance provider to cover necessary prescriptions not on the official list.

“It makes me angry inside, especially because I worked my whole life,” Bach-Nuñez said. She asserted, “The insurance companies are becoming our doctors, and they are not doctors.”

The Pharmaceutical Research and Manufacturers of America, or PhRMA, which lobbies for the industry and patient access, recently claimed there was a staggering number of prescription denials. “70 percent of patients face rejection on their initial attempt,” PhRMA said.

Health-insurance companies dispute this. America’s Health Insurance Plans (AHIP), the industry’s trade group, countered in a statement that the research is misleading. AHIP alleged that “Brand drug makers bankrolled this misleading research to distract from the unaffordable prices they alone set and raise.”

In Fort Lauderdale, cardiologist Dr. Tiffany DiPietro reports that a prescription that she writes for a patient is rejected almost daily. “All insurance companies have a formulary, so they want you to try what’s cheaper,” she explained. “But the best medicines are newer, one company makes it, and they set the price.”

The high cost means some patients in South Florida simply go without. Shirley Hanson, an 82-year-old home health aide, never picked up prescriptions to treat blisters on her arm. “I’m 82, and I’m still working. I can’t afford my prescriptions,” she said.

“In my humble opinion, they hope you give up,” Dr. DiPietro said of the denial process, noting she can spend “one to two hours on the phone hoping to get through.”

However, AHIP maintains that “Health plans approve the vast majority of claims and connect patients with care that’s effective, safe and as affordable as possible.”

Bach-Nuñez refused to give up. After two appeals and two and a half months, she is now paying $12.65 for her COPD medication, which has a shelf price of $765. She said that “within three or four days with this medicine, I wasn’t getting out of breath.”

What to do if your insurer denies coverage

• Appeal the decision and work with your doctor on the appeal process before submitting it to the insurance company.
• Look for discounts online directly from the drug manufacturer and prescription cards.
• Apply for a grant from a nonprofit organization such as The PAN Foundation, which might offer a cheaper price on your prescription.

This report was produced by Miami Herald news partner CBS News Miami.