5 Things I’m Grateful for This Black Friday…and Always

Photo: Memorial Sloan Kettering Cancer Center

These people, places and things (but nothing with a SKU or UPC code) are bringing me joy and gratitude this Black Friday – and all year long.

5. Living and working in New York City

Despite my love-hate relationship with the city – its noise, crowds, transit system, and other offerings, good and not so good – there’s nothing quite like helpful New Yorkers, bodega coffee, or crossing 23^rd Street against the light on a holiday morning when New York shows us its quiet side.

4. William, my trainer

From crunches to rowing, lifting to running, boxing to jumping, the two hours I spend under William’s guidance each week make me a partner in caring for my body, building physical and emotional strength, and expanding my world with a small view into the life of an Ecuadorian immigrant family.

3. Health and the insurance to help guard it

A visit to the Evelyn H. Lauder Breast Center at Memorial Sloan Kettering Cancer Center right before Thanksgiving each year not only reminds me not to take my health for granted, but also to remember the hundreds of people who, whether they know it or not, play a role in ensuring my inherited genetics don’t determine my destiny.

2. The minyan at Temple Shaaray Tefila

In a large congregation, it’s a blessing to slip into “my pew” on most Saturday mornings and to connect to the people around me, and the prayers, music, and rituals that will unfold in the coming hours. Torah study, too, connects me to my (ancient) people, unchanged by the millennia, but ever-changing because of my own new perspectives, knowledge, and “ah-ha” moments.

1. Family and friends

More than an individual's presence, it is the love, support, joy, laughter, humanity, honesty, attention, time, and more that we share with one another that makes my life rich and full. Thanks to the people in my village and in my world – near and far, new and not so new, known and unknown – I truly have everything I need.

No, My Mailman Isn't My Pharmacist

Dear The Mums,

If Donald Trump and the current American political scene aren’t enough to keep you rolling in your grave, here’s something that will send you spinning.

On my way home on Thursday night, I stopped into CVS to pick up a refill for the generic version of Lipitor, which costs me about $12. When the pharmacy tech guy – someone I’d never seen there before -- rang it up, it was $98.99. I told him I was sure that wasn't the correct price, but when he didn’t offer to investigate, I swiped my card, took the bag, and left the store.  

Once home, I called the pharmacy and spoke to someone who looked at my record, confirmed that the price was not correct, and said I had a week to return, show my new insurance card and get a refund.  

So last night on my way home, I again stopped into CVS, this time to give them my insurance card and get the refund…or so I thought. Instead, the pharmacist told me that coverage had been denied because I had reached the max on the two “retail refills” allowed on my plan. Now, she said, I’d have to use the insurance company’s mail order pharmacy or obtain an override from the online pharmacy to continue to get refills at CVS. 

I’ll bet your ears were ringing then because I told her that my mailman isn’t my pharmacist and I wasn’t going to order drugs online. “I don’t disagree with you,” she said, and gave me the number to call OptumRx to request the override so she could issue the refund and give me the refill.  

When I finally was able to speak to an OptumRx rep, he talked so fast I could hardly understand what he was saying, never mind that I standing at the pharmacy counter in CVS at the height of the after-work rush. Perhaps worst of all was the chiding tone he used to tell me that if I’d “done what I was supposed to do and contacted the company in January, when they first put a “flag” on my account, I wouldn’t find myself in this position now, but by the end of the call he would be able to grant the override I requested.” He then went on auto-pilot at warp speed to tell me exactly how much I would save by purchasing drugs through the insurance company’s mail order pharmacy. 

Needless to say, none of this information cooled my boiling blood.  

Using my firmest, OMG-I’m-so-angry voice, I told him – through clenched teeth, I think – that I understood the cost savings, but I was in the pharmacy to pick up a refill. I also told him I was not prepared to use an online pharmacy under any circumstances, and that I needed an override immediately. I didn’t bother telling him that this was the first I'd heard about the limit on “retail refills” or that it’s my prerogative to fill prescriptions at whatever establishment I choose, and my reasons for doing so are not any of his ^%#^&$%$%#!#@%^ business. No, I was too sputtering mad to say any of that. 

Yes, in the end, he granted the override, and I was able to obtain the refill at CVS for the $12 I've been paying since January. So, as Daddy would say, ente gut alles gut. 

But… 

If this retail refill limit is, in fact, part of our new prescription plan, it remains to be seen whether my other maintenance drugs also will be declined when their third refills come due later this month. I’m curious to know, too, if I’ll have to jump through these same hoops to get overrides on each of those and whether I’ll have to do so for every third refill, or if the one override that’s now in place will be sufficient for all refills going forward. 

Stay tuned…and thanks for appreciating how maddening this scenario is (I know you do!) because I’m sticking by my belief (and yours, too!) that my mailman isn’t my pharmacist. 

~ Boo!  

P.S. I know I should be grateful to have decent health insurance that includes a drug plan, but the whole scene is such a racket these days that I'm miserable and frustrated in my gratitude.

Glutton for Punishment?

Note:  Thanks to my friend, Frume Sarah, I recently signed up at “the red dress club” and now receive regular writing prompts twice each week.  The first one—“gluttony”—arrived in my inbox earlier this week.

Dear Medical Insurance Provider:

It’s really very simple, and yet you just don’t seem to be able to get it right. 

On March 9, you issued a $100 check to me as payment for services that I’d received from an out-of-network provider.  Trouble was, you factored into your calculations a $25 co-pay that I (rightly) hadn’t paid.  (Remember, this was an out-of-network provider and thus there was no co-pay.)  And so I called you and listened to cheesy music until it was my turn.  When you finally got on the phone, thank goodness, you understood what I was telling you, apologized for the error and submitted the claim for reprocessing.  About a week later, a check for the additional balance due me arrived in the mail.

On April 18, you issued a $360 check to me as payment for services that I’d received from an in-network provider.  This time the trouble was that—as is the practice with such providers—I’d paid the requisite $25 co-pay and expected that the doctor’s office would bill you.  When I called to tell you that a check had been issued to me in error, you told me to sign it over to the provider.  If I did that, however, he or she could conceivably be paid twice.  And so the uncashed check sits in my ever-growing “Medical Insurance” file.  One day, I’m sure you’ll figure out the error and come looking for that money, and I’ll just return the check to you.

Yesterday, you emailed an Explanation of Benefits to me that detailed payments due me for services that I’d received from a (different) out-of-network provider.  Like the first time, though, you again factored into your calculations a $25 co-pay that I, once again rightly, hadn’t paid.  And so once again, I called you, listened to cheesy music until you came on the line and, thankfully, understood what I was telling you, apologized for the error and submitted the claim for reprocessing.  With any luck, when the payment arrives in the mail, it will be for the correct amount.  Needless to say, I’m not too terribly optimistic that it will be.

So, Medical Insurance Provider, let me fill you in on how it’s done.

When I see a provider who is in your network, I’ll pay a $25 co-pay, the provider will bill you and you’ll pay him or her a predetermined negotiated rate—generally less than what he or she charges—for the service provided to me.

When I see a provider who is out of your network, I’ll submit a claim for the full amount, you’ll tell me that the usual and customary charge for that particular service is some amount less than what I was charged and then, if I’m lucky, you will, without factoring in a co-pay that I didn’t lay out, issue a check for 80 percent of the lesser amount.

I hope this information is helpful to you, Medical Insurance Provider, and that henceforth you’ll use these guidelines when processing my claims.  Thank you for your careful consideration of this matter.

Sincerely yours,
JanetheWriter

R