Second-Guessing the Experts

I’m a migraine sufferer. I have a headache pretty much every single day, although most of my headaches aren’t bad enough to “put me down” so I mostly function.

I used to take Imitrex (100mg sumatriptan succinate) for migraines, but found that it tended to give me the shakes and sweats a bit and I would feel a little “off” after taking it. I mentioned these side effets to my neurologist, and he mentioned the new drug, Treximet, which is a formulation of 85mg sumatriptan and 500mg naproxen, formulated together specifically to address the side effects I had mentioned. Of course I’m sure the fact that the manufacturer’s Imitrex patent was about to expire had something to do with it too. But the fact is that it did indeed help me with exactly the side effects I had experienced, and it turned out to be a much better match for me as a medication than Imitrex had been.

Fast forward a year or so. I change employers and insurance companies, and I go to refill my Treximet prescription, only to discover that with my new insurer, it is not on the list of covered medications.

Why not? Well, there is a list of five other medications that they will cover for migraine, which their panel deems to be sufficient, including Imitrex.

But, you see, I’ve discussed those medications with my doctor, and tried Imitrex, and we settled on this one, because it’s what’s best for me. So I’d like to use this one. I call up the insurance company to find out how to get this covered.

I have to write a letter to their “appeals” department and have my doctor explain that he would like to have me take this drug instead of a different one, and wait several weeks to see what they say.

This seems wrong to me.

Because my doctor already wrote a note like that. It’s called a prescription.

You know, an “Rx”. The little dealio where a “Doctor”, who is a person that has to go to school for a long time and take very specialized classes that cost lots and lots of money, and is generally recognized to be building up some form of expertise in the treatment of illnesses and medical conditions, consults with someone called a “patient”, who is someone who has an actual illness or condition (generally a person, often a decent one, sometimes even one who pays insurance premiums and/or contributes services to an employer who pays them on his or her behalf), evaluates that person’s actual needs in their actual circumstances, as opposed to generalities in textbooks and case studies, often in the actual presence of said “patient”, and then decides among several medication options, choosing the one that he or she feels is best for that particular patient for his or her particular needs and circumstances, and then writes them down in on a little piece of paper, which is generally access-controlled and tamper-proof, in some sort of scrawly, nearly-illegible cipher that is decodable by someone called a “pharmacist”, who can then dispense the medication to the patient.

But no. The “panel” is effectively saying, a priori, “we think all migraine patients should take one of these other things instead.” Well, gosh, mister panel. If my doctor (who is a nationally recognized leading expert in the treatment of migraines, and who knows me as an actual patient rather than as a statistic or simply a source of insurance premium revenue) thought that one of those would have worked better, maybe he would have written one of those things on that little slip of Rx paper, instead of what he actually did write.

“But we can’t have all the riff-raff (our customers) buying all these expensive drugs willy-nilly! We must accuse them all of using ignorant doctors, and second-guess them, and make them re-justify their decisions, because we know better.” Or at least we can pretend we know better, in the hopes that some of them will just bend over and figure it ain’t worth arguing about it, and we can save a boatload of cash in the process. Not our problem if their actual quality of life suffers as a result.