Photo by Christopher Campbell on Unsplash

Right now, I feel like I’m drowning in a sea of frustration.

Due to income changes, our insurance changed this year from an affordable Health Insurance Marketplace plan to Alabama Medicaid. This change has, frankly, felt like a disaster from day one.

Let me be clear on one thing: almost every individual person I have spoken to — both during the process of the insurance change and while trying to get my ducks in a row health-wise after the change-over — has done their absolute best to be both kind and helpful, and I’m deeply appreciative of that. This post is not about knocking any individual person that I’ve been dealing with in trying to manage my care and the issues that have arisen since this change.

This post is about me expressing my frustration at the roadblocks, obstacles, and red tape I have had to deal with since this insurance change, particularly in the context of being able to get my Ozempic prescription.

The Timeline:

  • November 2021 – I contact Health Insurance Marketplace by the deadline and provide them with the necessary income information, etc. that they require to help people find affordable insurance plans. As it happens, due to income changes for our household, we happen to qualify for Alabama Medicaid now. The very nice lady at the Health Insurance Marketplace tells me that because I’ve qualified for full Medicaid, I will no longer be on a Health Insurance Marketplace plan, and I don’t need to do anything else besides wait for Medicaid to contact me.
  • December 2021 – I receive a letter from Medicaid confirming that I qualify to receive full Medicaid, and giving me my Medicaid number. (I never received my Medicaid card, though, and just had to put in a call yesterday to request that another one be sent.)
  • January 2022 –
    A) My Mom’s bank account is billed over $500 for a BCBS Health Insurance Marketplace plan (which would previously have been paid for by the tax credit premiums), even though the lady I spoke to in November told me I was no longer enrolled and wouldn’t have to do anything else except wait for Medicaid to contact me. Naturally, Mom called me FREAKING OUT at that much money coming out of her account and going to BCBS when I am no longer supposed to have insurance through them. (Trust me, I understand that the freaking out is warranted. I would, too, in her position.) So, I spend several hours on the phone with her and with BCBS and the Health Insurance Marketplace to straighten this mess out. BCBS cancels the coverage and agrees to refund Mom’s money, minus the 6 days in January that I had health insurance coverage through them before we caught this fiasco and tried to fix it. It took like a month for them to actually get the money back into Mom’s account, though.

    B) I go to my annual at my OB/GYN’s office and am doing really well on the Ozempic that she’s had me on for almost a year now because I can’t take Metformin. I vomit violently, nonstop for days on end any time I attempt to take Metformin to treat my PCOS. It does not work with my body. Ozempic, thankfully, works great and has had my PCOS under control for quite a while now. Upon arriving with my Medicaid letter, I find out that this OB/GYN who is very good, and who I happen to like a great deal, doesn’t take Medicaid insurance unless you’re pregnant. But I like her and have been doing well with her, so we pay over $100 out of pocket for the appointment and go on about sending the pharmacy my Ozempic prescription, which has been fine and covered as a stable therapy on my previous insurance for about a year now.

    C) I remember to call the pharmacy and let them know that my insurance has changed. I give them my new Medicaid number. They submit my Ozempic prescription and Medicaid refuses to cover it.

  • February 2022 –
    A) We go through the whole prior authorization shitshow. Medicaid refuses to cover the medications again. I call Medicaid and explain that this medication is necessary for managing my PCOS. They are confused as to why it’s being denied if I was using it before as a stable therapy. I have to explain that I was basically forced to change insurance from the Health Insurance Marketplace BCBS plan to Medicaid due to changes in our income. I’m new to Medicaid, but not new to taking this medication to treat my PCOS. She says it shows that it was submitted online, not via fax, and maybe that’s the reason it’s being kicked back. They should submit it via fax. I call the OB/GYN’s office and let them know this info.

    B) February 8 – My doctor’s office submits another PA request along with a letter of medical necessity, which Medicaid denies again. When I call Medicaid and ask why, they say that the request on February 8 in their system didn’t contain the proof of stable therapy from the pharmacy. The nice lady at Medicaid looks into things and tells me it appears to have been submitted wrong when she checks it in the system on her end (Medicaid). She’s very helpful and details what all they need from my OB/GYN’s office for it to have a better chance of not being rejected. She says that Medicaid needs proof of stable therapy usage from my pharmacy (which I assume the OB/GYN’s office can access), a letter of medical necessity, and supporting proof and that all of these things MUST be sent at the same time/along with the Prior Approval request. I call my pharmacy and tell them I need proof of stable therapy. I drive up there and get the printout myself. I also call my OB/GYN’s office (which is now closed at this point) and leave a message relaying the list of information that Medicaid requested that they send along with the next PA.

    C) February 9-10 – Several confused phone calls/a series of phone tag between me, the OB/GYN’s office, and Medicaid.

    D) February 11 – I get a call back from the OB/GYN’s office. They seem confused/seem to think that they’ve sent everything they needed to send to not be denied, and don’t understand what can be done differently. I explain that Medicaid also wanted proof of stable therapy from my pharmacy. I went and got a copy of that printout myself, and I can fax it to them if they haven’t already got a copy of that. I go to my mom and dad’s house and attempt to fax it, but I couldn’t get the fax to go through at all before closing time. This is a Friday. I leave copies by the fax machine at their house with the request that they try to send it on Monday after the OB/GYN’s office is open, operating under the assumption that once the OB/GYN’s office has ALL of the things that Medicaid requested they send, they will re-send the PA request for this medication that I am having a great deal of trouble functioning without. I have spent every day since February 8 at this point operating under the assumption that my OB/GYN’s office has intended to re-submit things the way Medicaid requested. I just want to be clear about that point before we move on.

    E) February 14 – My father successfully faxes my OB/GYN’s office the missing piece of information, the proof of stable therapy from my pharmacy, that Medicaid insists will get my request approved rather than denied. I call to double-check with Medicaid because I have been led to believe that at least one more PA request has been put in since February 8 while I’ve been pouning the pavement and doing all this legwork to figure out what’s wrong and fix the issue. The lovely lady at Medicaid informs me that no, my OB/GYN’s office never submitted a PA request that included the proof of stable therapy that I have faxed them on this date, and — in fact — the last PA request they got at all from my OB/GYN’s office was on February 8. I call to inform my OB/GYN’s office of the good news that they now have the proof of stable therapy paperwork they need to submit the PA to Medicaid and not be denied, only to be informed that they don’t believe they should submit the paperwork again with this missing piece of information because they are under the impression that they will continue to be denied because the request is coming from an OB/GYN’s office. So, rather than re-sending with the missing piece of paperwork I’ve worked so hard to get faxed over to them, they’re going to refer me to an endocrinologist’s office instead, in the hopes that the endocrinologist will have better luck with getting Medicaid to approve the PA for my Ozempic. I’m pretty frustrated by this and try to explain again that they didn’t have the proof of stable therapy from my pharmacy the last time that Medicaid shows them having submitted a PA request for the Ozempic on February 8. The person I was speaking to at the time contradicted me and claimed that they sent everything Medicaid had requested from them on February 8, but Medicaid claims that the only thing holding us up is the proof of stable therapy from the pharmacy, which I JUST faxed them on February 14. Despite that, she claims that they can’t submit again and don’t see there being a different outcome. We hang up. I have the realization that there’s NO WAY they submitted everything they were supposed to on February 8. They didn’t HAVE the proof of stable therapy paperwork from the pharmacy until February 14, and I’m not going to lie, realizing that REALLY upset me. I was giving them all the pieces, and for whatever reason, they were unwilling to submit again now that they had everything they were supposed to.

    F) I take the number she gave me for the endocrinologist’s office and call them to try to set up an appointment through them because obviously they’re not going to do what Medicaid said they needed to to get my Ozempic prescription approved through their office. The endocrinologists’s office tells me that they need an insurance referral, my labs, and the office notes from my last few appointments to get me set up for an appointment with the endocrinologist. So, I call the OB/GYN’s office back and let them know the list of things the endocrinologist’s office said they needed to get me in over there.

  • February 15 – 20 – I hear nothing from either doctor’s office, meanwhile I have now been without my Ozempic shots since early-mid January.

  • February 21 –
    A) After being off my period for two days, I suddenly start bleeding so heavily it scares me. I go through 4 heavy duty maxi pads between 7:30 AM – 12:00 PM.

    B) Freaked out because I never bleed this heavily, I call the OB/GYN’s office to let them know I have a problem. They work me in at a 1:45 appointment to check things out. I go through a fifth maxi pad and have to put on a sixth one during the course of this visit, during which they conduct a pregnancy test and a vaginal ultrasound. The pregnancy test is negative, and the ultrasound shows that I have two cysts right now, one on each ovary. I’m not surprised, since I’ve been without my Ozempic for so long. (I fully expect that they will both rupture at some point in the near future if we don’t get the Ozempic situation figured out. I’ve been dealing with ovarian cyst ruptures, which are excruciatingly painful, by the way, since my 11th birthday.)

    C) My OB/GYN tells me that I’m having an anovulatory cycle, and that that and the cysts that have appeared are probably both due to me having gone without my Ozempic since early to mid January.

    D) I take that opportunity to, while present at this visit, make clear face-to-face that they did not have the proof of stable therapy from my pharmacy until I faxed it to them on February 14, and that Medicaid was very clear that the last PA request they received was on February 8. Once again, they insisted that the endocrinologist they’re referring me to will have better luck getting Medicaid to approve it. She asks about that, and I tell her that I haven’t heard back from the endocrinologist’s office at all, but I did call and let them know what things the endocrinologist’s office had requested from them in order to set up an appointment for me. They insisted that they also sent everything the endocrinologist requested from them, but the doctor has the nurse re-send the info while I’m there anyway.

    E) The OB/GYN gives me enough Ozempic samples to last me 8 weeks at the lowest (0.25) dosage while I’m there, hoping that will last me long enough to get me in with the endocrinologist. She asks me to look into possibly getting my Ozempic through a Canadian pharmacy, which I’m not opposed to. I’ll give updates on that if I have to go that way.

    F) I pay $100+ out of pocket and leave, grateful for the samples at least. On the way home, I call the endocrinologist’s office to ask if they ever recieved my paperwork. They say they’ve been waiting on an insurance referral for me, as well as for my labs, for several days now. I call the OB/GYN’s office and let them know what the endocrinologists’s office says they’re still missing for me.

    G) I get home and have to change into my seventh maxi pad for the day and do my first 0.25 dose of Ozempic from the samples.

    H) I go through my 8th maxi pad for the day by 8:00 PM, but the bleeding finally slows down within a couple of hours of the Ozempic shot.

As of today, February 24, 2022, (which is my 33rd birthday, btw), I have once again not heard anything back from the endocrinologist’s office regarding an appointment with them, and am still at a stalemate with Medicaid regarding covering my Ozempic for PCOS and insulin resistance therapy.