What would you do if one day, the insurance that you paid into for over two decades, stopped paying for your life-saving drugs?
Susan Unger is a 64-year-old New Yorker. Her life’s story can be traced across the city. She grew up in Long Island and began her career in the performing arts in Manhattan. She then moved to the New York City Housing Authority, where she still works as a Community Coordinator. A Queens resident for almost 23 years, she rents a one-bedroom with her dog, Wookie. She sings, plays guitar and paints. She even wrote a children’s book, Moosey Travel Club.
Everything changed a few months ago. Ms. Unger went to get her three diabetes prescriptions and was told they were no longer covered by her insurance plan. She was given no explanation, no apologies, just a much larger bill for her vital daily diabetes medicine. Fortunately for Ms. Unger—and for anyone confronted with the same situation—she was able to get to the bottom of it.
We spoke to Ms. Unger about how she first found out about the sudden lapse in coverage, what she did about it, and what you can do if the same thing happens to you.
WTP (We The Patients): You recently experienced a sudden lapse in your diabetes medication coverage. Your Aetna insurance plan, for which you pay premiums, simply stopped covering your medications one day? Can you explain what happened?
SU (Susan Unger): For two years, I’ve been on my diabetes medication. Three months ago, all of a sudden, they weren’t covering my diabetes medicine anymore. Metformin, Jardiance, and Trulicity. With Trulicity, I get a shot once a week. It’s not insulin, but something that creates insulin in your body. The other two, I take every day. Aetna covered my diabetes medicine for the last two years and then all of a sudden out of the blue, I went to fill a prescription at the pharmacy, and they said it wasn’t covered!
WTP: That had to have been a shock. What did you do?
SU: The first thing I did was I called Aetna. I was on the phone for three to four hours, over a two-day period. They kept saying my plan didn’t cover it, and that’s not true—the plan had been covering it all along! Two years! All of a sudden, it’s not covered? Not in your plan? I said, “let me speak to a manager.” They had me talking to all these people and nobody gave me a sense of what was going on.
WTP: How did you figure it out? How did you get to the bottom of the situation?
SU: I stayed on the phone! Finally, they put me onto this group special coordinator something-or-other who said they have the right to stop covering [my diabetes medication] at their choosing. I believe this is a scam.
WTP: Can you elaborate on that at all?
SU: I think what they do is they don’t think the patients are going to challenge them, so they stop covering and the consumer has to pay for it. They think they have no choice! Because I was persistent, they turned me onto this other such-and-such coordinator, who said something like “Oh, we can change that in your records” so my medication was covered again—like it always had been! I really thought that was suspicious. They must pull that on everybody and try to get away with it.
WTP: What made you think something was off here?
SU: It made no sense! At their whim, they decided they were not covering it. Trying to tell me it’s not in my policy! I couldn’t make this up! I took care of it, but anybody even a little less persistent could really get screwed and I think that’s the end goal. And I think that’s really horrible. They had me scared, I don’t have that kind of money.
WTP: What would the difference have been, buying your diabetes medicine outright versus with your insurance?
SU: With insurance, Trulicity and Jardiance is a $10 copay and Metformin is a $5 copay. But if they’re not covered, we’re talking hundreds of dollars.*
WTP: So, would your advice be for other insured people to trust their gut?
SU: Yes. Absolutely. I just felt that something was wrong. All of a sudden, [they] change their mind? Nothing had changed in my policy. I had been paying my bills, paying my premium. The randomness of it really freaked me out. So I can’t have medicine now? That’s not right.
WTP: So, a takeaway is to challenge them, and stay on the phone?
SU: Yes. You have to. And one thing I can say on behalf of drug companies, something positive, is you can sometimes go to the manufacturer [website] and get a coupon for a better copay. I’ve done that. It’s something everybody should know.
* According to the Jardiance website, “The current list price for a month supply of JARDIANCE is $492.85.”
According to the Eli Lilly Trulicity website, “The list price of Trulicity is $759.40 per month.”
Because generic formulations are available, out-of-pocket Metformin prices vary but are considerably lower.