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  #21  
Old 08.06.2019, 17:16
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Re: Dependent on medicine the insurance won't cover

If the insurance kicked back 3000 CHF to you for previous prescriptions, I’m not sure we use the same definition of inexpensive medicine.

Certainly I appreciate your right to privacy, but I have to say there appears to be some very unique elements to your situation.
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  #22  
Old 08.06.2019, 17:35
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Re: Dependent on medicine the insurance won't cover

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You say it is not expensive so maybe it is an over-the-counter drug? Those are never covered even if you have a prescription for it.
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That's not correct. Dafalgan is available OTC and also paid for under prescription.
There are loads of OTC medicines that are covered by the health insurance.
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  #23  
Old 08.06.2019, 17:44
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Re: Dependent on medicine the insurance won't cover

If I've understood it correctly, you were prescribed tge medication, bought and used it, then the medical insurer declined to pay. They say - now - that at tge the time they sent you a letter explaining why they won't cover it. You can't recall seeing that letter or can't find it.
Just ask them nicely to please send you a copy. They probably will. Especially if you ask on a paper letter in an envelope, or in a phonecall to whomever has recently told you about that letter.

Later, the medical insurer did, after all, reimburse you.

Then the doctor prescribed it again/still and now the insurer is declining to cover it and also not the generic, even through the medication and the generic are both on The List.

This is all the more reason to ask for a copy of the letter in which they set out their reasons for declining it.

Perhaps, for example, it is regarded as a medication for treating an acute illness, whereas you appear to be taking it long-term. Or as ASwissInTheUS said, perhaps the doctor is prescribing it for a purpose (e.g. a useful side-effect rather than its primary aim) for which the insurer would be willing to cover a different medication, instead.
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  #24  
Old 08.06.2019, 17:49
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Re: Dependent on medicine the insurance won't cover

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Physicians are way too busy to check beforehand if a drug is covered or not.
Yes, this has certainly been my experience, completely.

Good on those doctors who did take the trouble, like yours, edot, and Mr Medea's!

My pharmacy, however, always advises me of exactly what will and won't be covered. I've found it very useful to maintain a working relationship at one pharmacy, rather than buying the medication from any random pharmacy en route.
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  #25  
Old 09.06.2019, 12:01
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Re: Dependent on medicine the insurance won't cover

Hi guys,
thanks a lot for your help.
Anyway, just wanted to clarify that my memory on how much money they returned and for what purpose exactly is kinda blur- it's been years since then.
So please don't build theories just off that.
Also this medicine is continuously prescribed- there was never any pause since I started and any generic substitutes were by advice of the pharmacist and the insurer just recently said they refuse to cover the original and all generic substitutes.
BTW I always paid at the pharmacy with the insurer's card and they later on send me invoices (only now I realize they're on the full amount, and not a partial amount)

Again, I apologize that I write things that are kinda blur in my memory. I will re-check all the facts and documentation and update here.
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  #26  
Old 09.06.2019, 12:25
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Re: Dependent on medicine the insurance won't cover

If the following conditions are met, the insurance must pay, no matter what they did or did not years ago.
- it's on the official list of approved drugs ("Spezialitätenliste")
- it's prescribed by a medical doctor
- it's used to treat a condition it is approved for in Switzerland (i.e. no off label use)
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  #27  
Old 09.06.2019, 13:59
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Re: Dependent on medicine the insurance won't cover

Something does not compute.

You have a doc prescription, for a covered medication, that has been sometimes reimbursed, sometimes not, over last several years. The insurance company sent you a letter declining, that you have not received.

Well it is not hard to get the letter again detailing the reason why they are not covering. Sans that, no use of any other info/argument.
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  #28  
Old 09.06.2019, 14:02
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Re: Dependent on medicine the insurance won't cover

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- it's used to treat a condition it is approved for in Switzerland (i.e. no off label use)
As we are being drip fed info by OP, I would suggest that this is in fact the actual problem, i.e. it is being used in a non-recognised manner.

Tom
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  #29  
Old 09.06.2019, 16:30
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Re: Dependent on medicine the insurance won't cover

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As we are being drip fed info by OP, I would suggest that this is in fact the actual problem, i.e. it is being used in a non-recognised manner.
Tom
Perhaps. We don't know that yet.

Edot cited an example of a medication which was not covered, and then suddenly was. This can work the other way, too.

The List is not static, but changes. Some drugs are added because of new successful tests, or because they were formerly very expensive but factors of the processing or quantities or expired patents caused the price to drop. Other drugs are removed because of bad experiences (if a medication formerly deemed efficacious later proves to have negative side-effects which at first went undetected).

In addition, what is deemed to be the central purpose and aim of a medication can change.

For example, Thalidomide (also known as Contergan) was initially given to pregnant women to help with "morning sickness" during pregnancy. It also inhibited cell-division and drastically and negatively affected the babies' growth in utero. Once that causality had been established, it seemed natural to ban the drug immediately. Later, however, oncologists took a new look at it, as slowing cell-division could be useful for patients with cancer. That turned the medication on it's head, as it were. What had been a negative side-effect became its prime use, and the fact that it lessened nausea (which plagues many on chemotherapy) was no longer the reason to administer it, but became a welcome side-effect.

That's just one illustration. It is at least possible that the drug OP is using is firmly on The List alright, but that its purpose has been re-classified.

This is also what I meant above about whether its use was for acute or for chronic conditions.

It is at least possible that OP's drug was first not deemed appropriate, then later covered, then later rejected... because of different phases of its application, as defined on/through The List.
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  #30  
Old 09.06.2019, 17:10
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Re: Dependent on medicine the insurance won't cover

If it is in fact due to off-label use it can still be paid by insurance in certain cases. The doctor may request it and the insurance may approve it. This should be clarified beforehand though (Kostengutsprache).
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  #31  
Old 05.09.2020, 15:37
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Re: Dependent on medicine the insurance won't cover

Hi people,
I think I owe you an update.
Apparently the insurer contacted my GP who was already retired, and asked him to fill out the official forms.
He never replied, so the forms were never submitted and the request was denied.

I've recently asked my new GP to submit the forms (as usual, for a fee).
At first he was reluctant and said "well, if the request was denied, is it wise to annoy the insurer?"

But I've asked him to start the process because it was never really done properly.

Now I've got a letter from the insurer, saying they will finance 90% of the medicine's cost from now on.
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  #32  
Old 05.09.2020, 15:47
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Re: Dependent on medicine the insurance won't cover

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Hi people,
I think I owe you an update.
Apparently the insurer contacted my GP who was already retired, and asked him to fill out the official forms.
He never replied, so the forms were never submitted and the request was denied.

I've recently asked my new GP to submit the forms (as usual, for a fee).
At first he was reluctant and said "well, if the request was denied, is it wise to annoy the insurer?"

But I've asked him to start the process because it was never really done properly.

Now I've got a letter from the insurer, saying they will finance 90% of the medicine's cost from now on.
So the denial was an error of sorts - had you old GP filled out the form , or told you the form needed to be completed, this would be moot.

I’d not be so happy with your current GP who was reluctant “to annoy” the insurance, but glad it’s been resolved. And thanks for updating everyone.
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  #33  
Old 05.09.2020, 16:38
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Re: Dependent on medicine the insurance won't cover

I have this argument roughly once a year, the insurance thinks my ADD will magically disappear and keeps asking for confirmation from my doctor that I do in fact need the prescribed medication. The doctor often forgets so they try to charge me, I tell the doctor to do the report and they do, boom, sorted. Annoying but how it is.
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  #34  
Old 05.09.2020, 16:45
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Re: Dependent on medicine the insurance won't cover

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As we are being drip fed info by OP, I would suggest that this is in fact the actual problem, i.e. it is being used in a non-recognised manner.

Tom
Sorry that it took so long to answer:

It's the most traditional medicine for this specific illness.
Nothing experimental/non-recognised.

Like insulin for diabetes, really.
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  #35  
Old 06.09.2020, 16:40
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Re: Dependent on medicine the insurance won't cover

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I have this argument roughly once a year, the insurance thinks my ADD will magically disappear and keeps asking for confirmation from my doctor that I do in fact need the prescribed medication. The doctor often forgets so they try to charge me, I tell the doctor to do the report and they do, boom, sorted. Annoying but how it is.
They do this yearly because ADD has to do with executive dysfunction. They know a good chunk of people with ADD won't get the letter to have it sorted out. The insurance company is being unethical to save money. Same thing with people that have PTSD and need to provide continuous documentation. This is extremely difficult for someone with PTSD to stay on top of.
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  #36  
Old 06.09.2020, 18:07
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Re: Dependent on medicine the insurance won't cover

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They do this yearly because ADD has to do with executive dysfunction. They know a good chunk of people with ADD won't get the letter to have it sorted out. The insurance company is being unethical to save money. Same thing with people that have PTSD and need to provide continuous documentation. This is extremely difficult for someone with PTSD to stay on top of.
I agree. It adds to the constant sense of overwhelm that is the bane of my life.
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  #37  
Old 06.09.2020, 18:38
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Re: Dependent on medicine the insurance won't cover

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They do this yearly because ADD has to do with executive dysfunction. They know a good chunk of people with ADD won't get the letter to have it sorted out. The insurance company is being unethical to save money. Same thing with people that have PTSD and need to provide continuous documentation. This is extremely difficult for someone with PTSD to stay on top of.
Even people with incurable, degenerative diseases such as Duchenne or spinal muscular atrophy have to report every so often to the IV that, yet, non-surprisingly, no magic cure nor miraculous event has happened and they are still bound to wheel chair with no prospect of ever getting out of it again.
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  #38  
Old 06.09.2020, 19:09
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Re: Dependent on medicine the insurance won't cover

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I have this argument roughly once a year, the insurance thinks my ADD will magically disappear and keeps asking for confirmation from my doctor that I do in fact need the prescribed medication. The doctor often forgets so they try to charge me, I tell the doctor to do the report and they do, boom, sorted. Annoying but how it is.
Although what I need is on the list. I need my doc to write a prescription for it at the beginning of each year. And my insurer still often misses reimbursing my bills!
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