My Son Is Being Denied Health Insurance Coverage For His Medication

My Insurance Company Is Denying Coverage For Meds My Son Needs To Breathe

Wendy Wisner

Both of my kids get asthma symptoms when they have respiratory viruses. It started when they were young toddlers. They’d start to wheeze when a cough came on, and sometimes their little chests would begin to retract, as they struggled to take in full breaths. There is nothing more terrifying than watching your child struggle to breathe. Nothing.

Thankfully, after a few urgent doctor visits, we figured out the correct combination of asthma medications for them, and they generally fared well. Yes, their asthma symptoms have kept both of us up many a night, but their meds seem to do the trick. I’m certain those meds have saved us many trips to the emergency room.

All of this is why I’ve been blind with rage lately as I’ve fought with my insurance company to cover my six-year-old son’s asthma medications. The problem boils down to the fact that we switched insurance companies this summer, and while our former insurance company covered his asthma medication, the new one does not.

Their reason? Well, the medication in question is one that he uses with his nebulizer (a machine that vaporizes asthma meds so that children can easily inhale them), and the insurance company says that he’s old enough to use a traditional inhaler instead.

What is this based on? I have no fucking clue, and neither does my son’s doctor. She prefers he use nebulized medications, especially because he is used to using them and they have worked for him for his whole life. She says that he might be able to use an inhaler, but we’d have to see. Some young kids are just not ready and can’t quite figure it out.

When I called the insurance company to complain, they suggested I ask the doctor to contact them to give us “prior authorization” for the medicine, citing the fact that using the medication would be a “continuation of care” for my son.

My doctor was on board with this plan. But as you can imagine, 25 million calls later – to the insurance company, the doctor’s office, the pharmacy, the doctor’s office again, the insurance company again, and on and on — nothing changed. The insurance company has continued to deny coverage for this medication.

Clearly they don’t give a shit about what is best for my child.

The good news is that as awful and infuriating as all of this is, I do have options. I can try the inhaler with my child and see if he can manage its use. It requires discipline to use one of those things – inhale and then hold your breath for the right number of seconds, rinse your mouth out afterwards without swallowing the water, etc. I can see if he’s up for it, though I do have my doubts. So does his doctor.

I also have to make sure this new medicine doesn’t have any bad side effects. Other asthma meds we tried made my kids stay up all night bouncing off the walls and made their bodies jerk involuntarily in all kinds of ways. The medicine they use now doesn’t, which is why I love it and want my kids to stay on it. I have no idea if the new medicine will be side effect-free or not, and I am not looking forward to testing that out.

If all else fails, my family can afford to buy a box of his asthma medication out of pocket. It costs about $250 for a box of 30 vials, which amounts to about $8 a dose. My son uses the medication about six times per year, for a week or so each time, so the cost is manageable for us. We would have to finagle our already stretched budget, but we could make it work, if we had to.

But that’s where my rage starts to boil over even more. What about families for whom buying a medication at full price is completely cost-prohibitive? What choices do they have? And what happens to their precious children when they aren’t on the right medicine or can’t get any medicine at all?

In fact, there has been an increase of diabetic patients who have not been able to afford insulin either because of lack of insurance coverage or because their deductibles are too high. Going without insulin is a death sentence for diabetics, and there have been cases of diabetic folks dying simply because their insurance company doesn’t cover their medication.

This kind of thing is becoming more common than people realize, especially as insurance premiums have skyrocketed, deductibles are through the roof, and insurance companies are becoming more choosy about what medications or services they will cover.

It’s a travesty – an unconscionable, horrible travesty.

I’m grateful to have health insurance for my children, and I’m grateful for government programs like CHIP (where my kids get their current insurance), Medicaid (which we were on when my husband was unemployed), and the ACA, which – despite its many flaws – has made it possible for more Americans than ever to afford insurance.

That said, the way we do insurance in America is bullshit and in desperate need of an overhaul. Families should not have to break the bank or go bankrupt to afford health insurance – and when it comes to any kind of life-saving medication or procedure, full coverage should be guaranteed. Period.

Health insurance is not a luxury. It’s a basic human need – like food, shelter, clean air, and safe streets. We guarantee each American child a public education, and yet we don’t guarantee coverage for their necessary medical services? What kind of hypocrisy is that?

I’m know I’m not alone in my utter rage here. I’m hoping that somehow our government will hear these voices of outrage, and freaking do something about it. Please, for the love, someone reform the healthcare system now – for our kids, for ourselves, and the next generation to come.