United Health Care and Oxford Health Plans...

... should be ashamed of themselves.

After much "hondling" with United Health Care/Oxford Health Plans they finally decided to suck it up and do what they should have long ago done and pay for Eliza's formula since it is her sole source of nutrition (as an aside this would NEVER had been an issue if the formula was consumed via a tube instead of orally).

On February 4, 2009 UHC/OXHP precertified both Eliza's formula and calorie supplement. WooHoo, such a nice birthday present for me. So I do what I am told to do by UHC/OXHP and call Medco, their pharmacy provider, to arrange for delivery. After 10 (TEN) hours of calls where I am alternatively told that Medco will direct ship the products and then that they won't ship the products, it is finally determined I need to find a retail pharmacy in my area to "fill" the precertified prescriptions. I am given a list of 26 pharmacies to call, and call I do. Not one of the 26 carries these products since, as one neighborhood pharmacist told me, "there is no profit in carrying products that have such a low demand." These are not standard shelf items.

I call the good folks at Nestle to see if they know of a pharmacy that carries these two products. Nestle claims they have no such list. I find this a bit hard to believe and suspect they much prefer me to continue to buy the stuff straight from them at a hefty profit. Nestle also advises they will not bill UHC/OXHP or Medco directly.

So I sally-forth to the online pharmacies and EUREKA! CVS.com is more than happy to fill the prescriptions! Life is grand, I make room in my small apartment for the cases of nectar that I am anticipating will arrive any day.

Then I get the email from CVS.com stating (are you ready) that UHC/OXHP/Medco have denied the claim since although they are precertified these products are not covered under my pharmacy benefit. Huh? If it is not covered under my "pharmacy" benefit, then one would wonder why Medco was involved at all, since Medco ONLY deals with "pharmacy" benefits and it was Medco that gave me the names of the 26 pharmacies to call.

So I once again dial the UHC/OXHP/Medco 800 number. By now I have spent in excess of 35 (THIRTY-FIVE) hours trying to get the products that UHC/OXHP has precertified. Four hours and three calls later I am told that these products are covered as a "medical" benefit and I need to go to a medical supply company. While I am clearly vexed at the waste of time, I am thrilled to place that call to Apria for the products. I am in luck! Apria carries them and they can be at my door in a jiffy!

Guess what happens next?

UHC/OXHP DENIES the claim from Apria. Why you ask? Because the products are NOT covered as medical benefits but rather are pharmacy benefits. Huh? No dear readers you are not confused nor is your reading comprehension failing you.

So to sum up:

February 4, 2009: the products are pharmacy benefits

February 10,2009: the products are medical benefits

February 23, 2009: the products are pharmacy benefits.

As of today "Jim" a supervisor was "looking into this" since he "felt" this was a pharmacy benefit. Since "Jim" managed to disconnect me after 97 minutes on hold today I am not hopeful that "Jim" has any idea what he is doing any more so than "Tammy," "Sharon," "Lucille," "Jennifer," "Arlene," "Suzanne, "Ronald" or "May" knew in my earlier calls.

I have now spent a full work week trying to simply obtain the products which United Health Care/Oxford has already approved. This is in addition to about 100 hours of my time trying to get the stuff covered in the first place.

This is just wrong and is a simple example of what is so very broken with our health care system. Caring for a special needs child and working full time is hard enough, do these people take some perverse joy in making this even more difficult? I think they do. I am sure UHC/OXHP dearly wishes Eliza was not one of their insureds. Surely they could have used the $2.7 million they have already spent on Eliza for a few swanky corporate outings.

To spite UHC/OXHP I will NOT move our company's group policy to another carrier but rather will make sure that every dime is sucked out of this wretched company. I will happily use my insomnia to their detriment and make their corporate "life" as miserable as I possibly can. Yes indeed.

CPSE and Preschool

Previously I had posted about the joys of touring the pish posh preschools under the blog post titled: Preschool. Since embarking on that journey several months ago, Eliza has had CPSE evaluations completed and I have begun to limit my tours and play visits to the non-typical a/k/a developmental preschools. There is certainly a different dynamic involved when you tour a school not with an eye to how swanky the doll playhouse is or whether or not all of the children wear Petite Bateau onesies.

I gave the integrated school one last look-see. On the appointed day I entered the school, toured three halls, peeped into a half dozen classrooms, the teachers' lunch room and what appeared to be an administrative office. The tour was, shall we say "self-guided." Odd you say? Yes indeed it was very odd to me that I was not only able to enter the school undetected but wander aimlessly through the halls for a good 15 minutes before a single adult ever asked who I was or if they could help me. Not the security one would hope for, is it now? So while I am sure I could convince the city that this school would be right for Eliza (it is not) I would be very hesitant as a tax payer to see $15,0000 to $20,000 of my city's hard earned shekels be given to this school under the CPSE program.

My next and last tour was of a developmental preschool touted to be a good competitor of the school I prefer that Eliza attend. I figured a tour of the competition would be helpful and maybe they could offer something new or different. The security was top notch so things started out on a good foot. Then I got to the waiting room. There was a rather large fish tank. The fish were dead. All I could really focus on was how the hell do you kill a carp? I mean really now. Those things can freeze outdoors in a pond and come back to life in the spring. And if you can kill a carp, that does not bode well for your ability to care for a child who is likely not as durable as a carp. I did continue the tour and was not all that impressed. I was having a bit of sensory overload from the sheer amount of stuff in the classrooms. And then there were the televisions. Since I can provide television at home, I do not consider it a bonus that my child would spend her preschool day involved in some old fashioned TV watching. The excuse was that there was bad weather so the children could not go outside. This is the northeast. We have bad weather for four months.

Sigh.

So I am armed with all of the information I need for my IEP meeting with the city. I have a wonderful service coordinator and am told that the Department of Education liaison assigned to Eliza's case is excellent. With any luck by mid-March the biggest preschool concern I will have between now and September is what kind of backpack to get for Miss Eliza.

I leave you with this observation:

Carp:


Not a Carp:

The March for Babies

No, I'm not marching to have another baby .... wouldn't that scare the heck out of some of you!

It's the annual March for Babies fundraiser for the March of Dimes. So far Eliza's team has raised $6,535 for the March of Dimes. This year we have set our goal at $3,465 which would bring our total to $10,000. Not a shabby goal (and you do all know how competitive I can be!)

So why should you donate to Eliza's Team?

Let's review:

Premature babies are not simply mini-babies who need a good few ounces of breast milk to fatten up and be sent home. Micropreemies barely resemble babies when they are born.

Eliza was born at 26 weeks 4 days gestation. She weighed 1lb 4ozs and was 11.5 inches long. A small bottle of Poland Spring water is larger.

Eliza had a half dozen blood transfusions in her first 60 days of life;

Eliza had over 500 (five hundred) heel sticks in her 100 days in the NICU;

Eliza had multiple umbilical lines for her first 20 days of life;

Eliza has had IVs placed in ever conceivable location, including her head;

Eliza was intubated for 67 days;

Eliza was not held by anyone, including me, until she was 25 days old;

Eliza was two months old before she reached 3 pounds;

Eliza had her first bottle on May 24, 2006, more than two months after her birth;

Eliza came home on June 23, 2006 after 100 days in the hospital;

Eliza was weaned off of oxygen on August 30, 2006;

Eliza didn't roll over until she was 11 months old;

Eliza crawled for the first time on March 14, 2007, the day before her birthday;

Eliza stood up for the first time when she was 13 months old;

Eliza walked for the first time just after she turned 17 months;

Eliza spends about 20 hours a week in various therapies;

Eliza has never been able to eat anything resembling a "meal" because of raging sensory issues;

Eliza generally tests at the level of a 24 month old in all areas, despite nearing her third birthday.

Eliza is alive today and thriving thanks to things like Surfactant which helped her premature lungs when she was born three months too soon. But every single day Eliza has to overcome huge hurdles just to be an "average kid."

I will always be eternally grateful to the staff at Lenox Hill Hospital for not only saving Eliza but giving her the best chance possible at a full and rich life.

But wouldn't it have been nice if I didn't have to owe such a debt of gratitude?

Wouldn't it be nice if other babies could avoid 100 days in the NICU?

So instead of buying another latte from Starbucks this week, make a donation to the Eliza Grace Team in the March for Babies.

You can donate to Eliza's Team by clicking on the widget on the left sidebar.

How can you deny this face:






We appreciate your support and if you would like to march with us, drop me a line for details!