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When Things Are Beyond Words

LaptopI’ve given up. Not given up hope, but given up trying to talk to Aetna. The manager we spoke to Wednesday and called back and left a voicemail with Thursday returned my call yesterday afternoon. More than an hour later, I was a wreck of a human being.

I was moments away from speaking to the President – Mark Bertolini – when his screener said “she was supposed to have taken care of this for you,” and transferred me to someone who said the plan I was on showed Pulmozyme as a Tier 2 med on a 3-tier open formulary plan. The system says I’m on a 4-tier plan, so Pulmozyme is a Tier 4 “specialty drug” and I was never able to get that other manager on the phone again because I didn’t get her ID number.

I’ve relinquished my control of the situation. I clearly can’t do anything to help things with my existing plan, so my brain and emotions have turned a corner to new ideas. I have not just sat idly by and let this happen to me; just the opposite – I’ve worked the situation until I was shaking and talking like a crazy person.

Now I have to let the system (the insurance regulators) do its thing pursuing the angle that we were illegally terminated from my old plan and not given options to pick a new one nor given a benefits book for my new plan. What “winning” that case means for me, I have absolutely no clue, so we are planning for the worst (they permanently terminate my plan and any future plans for me) and hoping for the best (I get a free plan for life and automatic approval of any drug for life at a set copay).

I’m almost okay with the worst-case scenario, but I have more research to do with HIPAA, having an open policy after receiving a certificate of prior coverage that is almost 60-days old (meaning I won’t be able to use that certificate to prove continuous coverage without a 63-day lapse unless I cancel this plan to get a new certificate), and how to ensure that any plan will cover these meds and my exams.

I looked around last night and found plans that would save us $400+/mo, but that sounds too good to be true. What isn’t covered? Would we be jumping from the frying pan directly into the fire? There really isn’t anything that we get tested for that isn’t normal, they’re just not normal things for 20-40 year-olds, so they sometimes require pre-certification.

So, since I’m completely spent on this, if you’re the praying type reading this, here’s my list:

  • peace – that no matter what we choose to do, things will still be unknown
  • rest – so I can be strong, continue working, and not get sick
  • wisdom – that we choose to do the “right” thing

Beautiful said the most awesome thing last night, which is what I want to end with so you can see how my wife rocks:

I was trying to think of the worst thing that has ever happened to us. I remembered it was you losing your job. Now we say that is the best thing that has ever happened to us. Maybe this will be the next best thing, we just don’t know it yet.


  1. Kristi Bowers says

    Praying for all of those things. So sorry you are having to deal with this. You have yourself one awesome wife 🙂 Love you guys.

  2. Ronnie Sharpe says

    I’ll keep you guys in my prayers. Lean on God brother. Keep doing the possible, so He can do the impossible.

  3. GREAT insight, Kristin!!!! Remember the scene during and a few days after Jesus’ crucifixion? The disciples thought the gig was up. They had never known such dark and hopeless times. They were completely discouraged and giving up.

    But while they were giving up, that was exactly when God was doing the greatest thing He ever did. It’s been my experience that when all seems lost and hopeless is when I need to watch and wait because God is about to do something amazing.

  4. Megan Murray says

    I’m sending prayers and good thoughts your way.  I hate that you have to deal with this, and I just sincerely hope the case turns out in your favor (and quickly, too).  

  5. Sara Capalbo says

    Sending as many prayers as I can muster.  I fight with the insurance company almost weekly…my pharmacy staff has seen my cry in frustration more than I’ve allowed any other person to see.  I hope that you have the best possible outcome to this situation…it just stinks all around that you have to deal with it at all.

  6. Ditto on all the comments below.  Praying for you.    Never had an insurance problem this bad but finding that one person who can fix it is critical.  I also wonder if you should buy one of those cheap phone recorders to record conversations with Aetna.  They do it on their side.  I remember trying to find the right person (authority and responsibility to fix the problem with my insurance company – Definity) and it took weeks and if I would have had a phone recorder it would have helped with the names and to show how incompetent most of these people are.   Just an idea.  

    After dealing with no pharmacy/insurance Colistin for a few weeks (luckily I had a few vials. set aside) I finally got to the right person.  They plugged in a code and “wamo” the problem was fixed.  I have received Colistin now for over 3 years with no problems.   Scary to think of going through that struggle again.  God Bless. 

    • It’s so convoluted or misrepresented or misinformed that we can’t even tell who knows what they are doing or who actually knows what because I get different reasons each time and at all levels clear up to the “I need to speak to the President” department. Right now, I believe them as far as I can toss them.

      Skype does auto-record calls, yes, but every time I put them on speaker on the cell the reception was too bad and they couldn’t hear me.

      I think we’ve found the answer, and it’s not with them. BTW, Cayston came the same as usual, but they have a much better assistance program that we’ve had to use from the get-go.

  7. Jesse, I’ve been following your story all along. My heart aches for you. I unfortunately see this happen all the time. Hopefully there will be resolution. My prayers go out to you.

  8. MiddleAgedLady says

    Aaargh!! I despise these situations as it’s just so draining. I’m sorry this happened to you and will be praying it gets straightened out quickly. Keep listening to Beautiful.