Today, Health Net’s Grievance and Appeals Coordinator, Jonathan F.(NO, HealthNet did not give me his last name, even though he knows mine) sent me a 249 page refusal to my appeal for insurance coverage for a prescription for Viagra, as prescribed by my neurologist.
“Huh? Wait. Isn’t that for men?” you ask. (Background music playing here with a small voice saying, “Hold please for the next available explanation. Operators are standing by).
Of the 249 pages, Jonathan F. copied 234 pages from a medical reference system called Micromedix 2.0 – Drug Details. 234 pages of drug details of Viagra Jonathan F stuffed that in a big fat envelope for me to read, along with a 3 page letter and some forms.
Jonathan F., why mail me 234 pages of copied medical mumbo jumbo that I’m absolutely sure makes no sense to you either. Are you mean? Stupid? Or just a fucked up piece of shit?
So let’s back up. What has happened to cause all this? A Health Net neurosurgeon attempted to remove my brain tumor. Even though he said that resection would be a “walk in the park,” the Health Net neurosurgeon must have been mugged in said park. I ended up with epilepsy and skull screws that wiggled out of my skull because that dumb ass didn’t have the sense God gave a carpenter to countersink screws.
I have tried and failed on 14 anti-seizure drugs. I have tried some of the drugs more than once with the last one causing heart failure and ALL of them having side effects that were more severe than the epilepsy. So, now I am on my last drug – ONFi, and it is actually working. Actually doing some good. Actually stopping some seizures with one really bad side effect. YUP. Sexual dysfunction. And trust me, I have NEVER had this problem.
I finally get up the balls (no pun intended) to speak to my neurologist about the issue. He says, “No problem. A lot of women have good luck with Viagra.” What the…? My face was as red as the carpet in my den, but still, I’m happy because here’s what I’ve given up for epilepsy:
4) Swimming by myself
5) Standing on ladders
And I sure as hell don’t want to give up sex, which is way more important (and fun) than standing on ladders.
After my neurologist fills out the prescription, I run to my pharmacy all excited and yet a little apprehensive because where I live now everyone knows everyone. Everyone is a neighbor, and they all talk. It’s a small town with a small town atmosphere, and I have a vision of my Viagra prescription being the talk of the town. Thankfully, one of my favorite neighbors is the pharmacy tech that day, so we kind of chuckle about the Viagra, but then, the bad news – the prescription has not been filled. Check back tomorrow.
I go back the next day. One of my not so favorite neighbors is working the pharmacy. She says with her mouth hanging open, ‘Viagra. You know that’s for men.” I couldn’t explain. I just couldn’t. I asked her to check again and she says the insurance (Health Net) is denying it. I have to appeal.
In the meantime, Health Net mails me a denial with this reason:
“Coverage of Viagra requires that the patient is male with erectile dysfunction. The patient is female.”
Did I mention Health Net sucks?
I appeal with a 2 page letter and my poor neurologist appeals with 56 pages of records and notes.
Jonathan F. sends me a copy of my neurologist’s 56 page appeal. Jonathan F attaches a note saying if you want to say something you better do it now. This time I fax my appeal after looking at Health Net’s website home page which says:
In the meantime, I decide I’m going to do what everyone else does. I’m ordering Viagra off the internet from a Canadian pharmacy that doesn’t require a prescription. I do it. And while the appeal with Health Net is in process, the “Viagra” from the Canadian pharmacy which doesn’t require a prescroption comes, only the drug is not called Viagra. It is called Fligra. That’s right – Fligra, and it’s made in India, but it’s supposed to have to same active ingredient as Viagra, which is Sildenafil Citrate. I follow my neurologist’s directions and end up doubling up the dosage. Nothing. Until 24 hours later – then bam. Yes, Fligra from India works only it’s weak and takes about 20 hours longer than it should.
And so now, you are caught up with my sex life which everyone on the internet is dying to know about.
Did I mention Health Net sucks and Jonathan F. (no last name) but HealthNet’s Appeals and Grievances Case Coordinator is a photocoping monkey?
When the final paper work came today, there amongst the 249 pages is a note from Jonathan F which reads, “Based on our review of the available information, Health Net’s Medical Director Lesley Blumberg, M.D., a Board Certified Specialist in Obstetrics and Gynecology, has made a determination to uphold the denial for the following reason: ‘This is a request for Viagra in a female commercial HMO member with Brown and Toland. The member’s plan covers Viagra for male sexual dysfunction up to the number of pills in the recommended drug list. The issue here is that the treatment of anorgasmia in women is an off-label use with a IIB indication in Drugdex.'”
Ummm, that’s why the appeal? And there’s no IIB in the 234 pages of the copy of Micromedex I was sent. Also, I’m unable to find Dr. Blumberg on the Health Net’s website at all.
Did I mention Health Net sucks?