January 26th, 2011

Insurance Company Cheese Shop Redux

I had an interesting exchange with one of our nurses this week about a long-term patient of ours.

The e-mails went something like this:

Got a fax from —-‘s insurance that his Lipitor won’t be covered anymore.  They will cover simvastatin, lovastatin, and pravastatin.  Let me know what you want to do.

He’s on darunavir, and all three of those statins are contraindicated because of drug-drug interactions. Rosuvastatin?

Checked with them — rosuvastatin needs prior approval, and will cost him a lot more, but less than Lipitor. I’ll get the paperwork ready.

An hour or so passes, and then this:

What dose rosuvastatin?

5 mg daily, thanks.

Another hour, and then:

Just heard from them — after all the fuss, they approved the Lipitor after all.  Seems they just wanted to waste our time.


Look, I get it that generics are usually more cost-effective than branded drugs.  And I understand that health care costs are wildly out of control, and one way of controlling costs is to use generics whenever they are safe and effective, which is most of the time.

But think about the absurdity of the above case.

  1. The insurance company is paying for this man’s antiretroviral therapy, so they must know he’s on darunavir.
  2. They nonetheless are suggesting he switch to a contraindicated generic statin drug.
  3. They initially refuse to continue covering a drug that is working well and that the patient has been tolerating for years, but grudgingly will cover a slightly cheaper alternative.
  4. They set up barriers to jump over and tunnels to crawl through (the “prior approval” paperwork) even though there’s sound evidence to back up the requested brand-name treatments.
  5. After the obstacle course is navigated successfully by our experienced nurse, they relent and say that they’ll cover the original prescription after all.

And here’s the best part:  The exact same thing happened last year with this patient — with the same insurance company!

Reminds me of the classic Monty Python “Cheese Shop” sketch, where the customer (John Cleese) methodically asks cheese shop guy (Michael Palin) for dozens of different cheeses — all of them unavailable. When Cleese asks at the end if they have “any cheese at all”, here’s the response:

No, sir, not a scrap. I was deliberately wasting your time, sir.

“Venezuelan Beaver Cheese?”

2 Responses to “Insurance Company Cheese Shop Redux”

  1. Ben says:

    And here’s the YouTube link: http://www.youtube.com/watch?v=B3KBuQHHKx0
    Remember the skit well.

  2. Greg Hunicutt says:

    “Cheesit! It’s the Fe…no, it’s the Insurance Monks! They rule almighty!

HIV Information: Author Paul Sax, M.D.

Paul E. Sax, MD

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