Dear Mr. Sheehy:
Since mid March I have been dealing with United Health Care regarding my fourteen month old son Michael. He was diagnosed with Infant Reflux at the age of six weeks. These transactions have been wholly unsatisfactory. The paragraphs which follow explain why.
Despite pursuing all proper channels for coverage of 15 mg Prevacid capsules, I was declined “prior authorization”. Up until Michael’s first birthday this medication had been covered at 30 capsules and then it was adjusted to 60 capsules based on his growth and weight gain.
After a phone conversation on Wednesday, April 5th with United customer service representatives, I was informed that both Protonix and Nexium are covered by United. However, the pharmacist advised me that neither of these medications is FDA approved for pediatric use. An over-the-counter alternative Prilosec, only is available in tablet form. The manufacturer of this drug states that it should not be crushed as that action reduces the drug’s effectiveness. I accept the expert opinions of the pharmacist and the drug manufacturer.
Michael’s doctor (a GI specialist) and the compounding pharmacist contacted United Health Care by phone and facsimile on several occasions. United customer service informed the pharmacist that they would cover Prevacid SoluTabs or packets. Unfortunately, Michael cannot take the SoluTabs due to his documented dairy allergy, while the quantity and composition of the suspension in the packets make it impossible to administer to my son with any degree of success. When the doctor called United Health Care a second time on April 19th for “prior authorization” it was declined again.
Each customer representative has been pleasant but unable to help. I have been told that I have to take this to a higher level and appeal the decision which may take up to thirty days through the appeals department.
Specifically, I need approval for Michael to receive Prevacid 15 mg time release capsules (twice per day dosage) as prescribed by Michael’s doctor and with concurrence of the compounding pharmacist.
Please advise me upon receipt of this letter of your intended course of action and time line. Should there be any question feel free to call at….
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