Why The Fucking Flexeril Isn't Covered Anymore.

More than a few of you have come across this situation by now I bet. In the midst of a chaotic, stressful workday you finally snag an easy one. Thirty flexeril. Yay. Two seconds and we'll have this one right out the.....

Then you see the insurance reject. Prior auth required. What. The. Fuck.

We've all come to expect this with the bullshit drugs of course. And the expensive meds  with cheap alternatives. I'm looking at you Lyrica. One of the missions of the insurance companies is to save money after all.

But Flexeril? Are you kidding me? The generic is cheap as dirt. So I repeat, what the fuck? "They must be doing this for no other reason than to get me to crack" you might be thinking. "They've decided they must make each and every prescription a herculean effort to get out the door. There is a war on my sanity. Because there can be no logical reason to slap a prior auth on a seven dollar med."

Oh but there is a reason my poor underinformed retail drone. Logical or not can be a matter for debate, but read on to find out  why that insurance company pain in your ass just got a little bigger.

I'm going to go out on a limb here and say that rejected Flexeril claim was for a Medicare Part D patient. I know this because while you, my poor pillcounter, are still stuck in that outdated world where insurance companies obsess about nothing but money 24/7, I have seen the future, that bright new paradigm where the health care powers that be now obsess about.......money. But in completely new and innovative ways. Where an obsession with the dollar can lead to scrutiny of the most absurdly inexpensive of insurance claims.

It works like this. Someone got the bright idea that Medicare should do more than just sit there and pay claims sent in by the health care professional types. That since he who pays the bills can make the rules, they should use their bill-paying influence to try and influence quality of care. It was decided that Medicare would start to rate its Part D plans like AAA rates roadside motels, with a one to five star system.

So far this sounds OK, right? After all, who could argue with an effort to improve medical outcomes?

Next step involves how to go about being able to show how a large, paper-pushing, figure obsessed bureaucracy is improving things for the oldsters. How do we do that? We can't really just go around saying, " 'Ol Doc Johnson over there at Blue Cross of Lower Damnation does a pretty good job, Five stars for them!!" now can we? We need things to measure, so as we can compare like to like. Outcomes this year versus outcomes last year, Blue Cross versus Humana. In short, we need a way to generate numbers we can use in place of that unreliable human subjectivity.

I'll stop here the throw in the olive in the martini. Those star ratings are worth big bucks to the insurance companies, as Medicare pays bonuses to the highest rated plans.  It's estimated that the difference between a 3 star and 5 star rating is worth about $200 million to the plan getting rated.

That's right, the principle of using metrics to judge performance that has been such an unqualified success in making chain drugstores efficient customer service utopias has now been expanded to the realm of clinical judgement. In this case, Flexeril, the muscle relaxant that been part of the standard treatment plan for all sorts of painful conditions for longer than I have been alive, has been classified by some bureaucrat as a "high risk" medication for the oldsters. And a plan that goes over a 3% threshold of "high risk" meds is ineligible for a 5-star rating, and all the megabucks that goes with it.

So yeah, good luck getting them to approve that claim.

Except chances are, if you have a brain in your head and no desire to torture yourself, you won't even try. You'll notice that even if you moved heaven and earth and got that claim approved, the five dollar copay that would result isn't all that much less than you would normally charge a person with no insurance at all. As a matter of fact,  you could just say hell with the insurance company, charge the person five bucks,  make just a little less on the prescription than you would have anyway, and save yourself a hell of a lot of hassle.

It's a win win. And if grandpa gets a case of brain fog after popping a pill or two and falls down the stairs, it still goes down as a win for the insurance, as they don't have a claim for the "high risk" med on file, and therefore won't get dinged.

Meet the new health care order my friends. Where everyone wins, except the drugstore who made a little less on a prescription than they normally would have. And Medicare, who just paid out a big bonus that had zero impact on quality of care. And grandpa, who just fell down a flight of stairs.

Which means no one really won except the insurance companies.

Which means the new health care order looks a lot like the old health care order.

But at least you know why that pain in your ass is a little bigger now.

You're welcome.

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Why The Fucking Flexeril Isn't Covered Anymore.
Why The Fucking Flexeril Isn't Covered Anymore.
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