BC for real medical reasons?

[royal_archer]

Is there any guidance for employers, insurance companies, etc to use (links please) to deal with this scenario?:

A female employee has a medically treatable condition which if unaddressed would lead to serious and medical distress/ eventual death or loss of major bodily function. (not pregnant, but something like a tumor). The medical condition can be treated with hormone theropy which has a secondary effect of temporary sterility. The employee insists the needed medication is for true health reasons and not to facilitate recreational / non procreative sex.

As the representative of the employer trying to determine if this should be coverage, how should they approach it? What degree of proof would be prudent / reasonable? etc.

I know all of our members have good personal opinions on this matter, but am hoping someone knows of an offical type reference.

 

[Anniejoe]

Surely there is medical support (in the form of a physician’s diagnosis) that would determine whether this is an appropriate hormone treatment or not?

 

[Franna]

I believe that the medical use of hormonal treatment is always justified,providing the individual/couple are informed of all of the medical complications,and know that regular use can result in sterility.

 

[raaucoin]

Is there any guidance for employers, insurance companies, etc to use (links please) to deal with this scenario?:

A female employee has a medically treatable condition which if unaddressed would lead to serious and medical distress/ eventual death or loss of major bodily function. (not pregnant, but something like a tumor). The medical condition can be treated with hormone theropy which has a secondary effect of temporary sterility. The employee insists the needed medication is for true health reasons and not to facilitate recreational / non procreative sex.

As the representative of the employer trying to determine if this should be coverage, how should they approach it? What degree of proof would be prudent / reasonable? etc.

I know all of our members have good personal opinions on this matter, but am hoping someone knows of an offical type reference.

The church has no problem with treating medical conditions with hormones( BC pills). What proof? well physicians use diagnosis codes. If the woman has been diagnosed with a condition, shouldn’t that be enough? It should be safe to assume the doctor wouldn’t be fraudulant and if he or she is, wouldn’t the moral culpability be on him/her?

 

[Rence]

Is there any guidance for employers, insurance companies, etc to use (links please) to deal with this scenario?:

A female employee has a medically treatable condition which if unaddressed would lead to serious and medical distress/ eventual death or loss of major bodily function. (not pregnant, but something like a tumor). The medical condition can be treated with hormone theropy which has a secondary effect of temporary sterility. The employee insists the needed medication is for true health reasons and not to facilitate recreational / non procreative sex.

As the representative of the employer trying to determine if this should be coverage, how should they approach it? What degree of proof would be prudent / reasonable? etc.

I know all of our members have good personal opinions on this matter, but am hoping someone knows of an offical type reference.

If the employee wants to furnish medical information to her employer about her medical status in order to prove that she needs hormone therapy to treat a medical condition, she can do that, and get a note from her doctor as well. It’s her information to give. If she is willing to give this information to the employer, the employer will be able to make his/her decision based on the medical information provided. The problem is a privacy issue for those women who do not wish to provide that personal information to their employer. This is why insurance companies, and health care providers, can never give that information to an employer. I’m not even sure if it’s legal for an employer to ask that information of his/her employees, so you might want to check. It may not apply if the employee actually furnishes the medical information herself and voluntarily, but it may open up a can of worms for other employees who want the ABCs coverage but who do not, for whatever reason, want to give their employer their private health information. It is private after all, and non of their employer’s business in the first place.

 

[Rence]

The church has no problem with treating medical conditions with hormones( BC pills). What proof? well physicians use diagnosis codes. If the woman has been diagnosed with a condition, shouldn’t that be enough? It should be safe to assume the doctor wouldn’t be fraudulant and if he or she is, wouldn’t the moral culpability be on him/her?

Employers wouldn’t have the diagnosis codes available due to HIPPA and privacy laws. She would have to furnish it herself.

 

[ValPal]

I know all of our members have good personal opinions on this matter, but am hoping someone knows of an offical type reference.

See “Humanae Vitae”

vatican.va/holy_father/paul_vi/encyclicals/documents/hf_p-vi_enc_25071968_humanae-vitae_en.html

Lawful Therapeutic Means

1. On the other hand, the Church does not consider at all illicit the use of those therapeutic means necessary to cure bodily diseases, even if a foreseeable impediment to procreation should result there from—provided such impediment is not directly intended for any motive whatsoever.

 

[raaucoin]

Employers wouldn’t have the diagnosis codes available due to HIPPA and privacy laws. She would have to furnish it herself.

Correct. However, if the employer simply is deciding on if they want to purchase insurance that would cover this situation- the insurance co, would make determination of payment based on Dx code. The employers decision would be a general one for any employee they provide for who might be in that situation.if the employer provides insurance with that coverage, then the insurance co. would pay for it if the diagnosis code warranted that treatment.

 

[Rence]

Correct. However, if the employer simply is deciding on if they want to purchase insurance that would cover this situation- the insurance co, would make determination of payment based on Dx code. The employers decision would be a general one for any employee they provide for who might be in that situation.if the employer provides insurance with that coverage, then the insurance co. would pay for it if the diagnosis code warranted that treatment.

Are they really set up that way? I don’t know for sure. I can’t see how that would not bring up discrimation charges for those women who want ABCs covered. But …

The insurance companies could do that, and the employer wouldn’t know any different, yes. But it’s just as simple to just use diagnosis codes that go with ‘painful periods’, which is subjective. So if an employee knows that the payments are set up in this way, they would just tell their doctor how painful their periods are, in addition to wanting to contracept, and the proper diagnosis would be used to get it covered. It wouldn’t be lying because pain is subjective and whatever the patient says it is.

 

[maryjk]

Are they really set up that way? I don’t know for sure. I can’t see how that would not bring up discrimation charges for those women who want ABCs covered. But …

Yes, they are really set up that way. Unless they are self insured. I don’t know how those work, because I have not worked with those.

The insurance companies could do that, and the employer wouldn’t know any different, yes. But it’s just as simple to just use diagnosis codes that go with ‘painful periods’, which is subjective. So if an employee knows that the payments are set up in this way, they would just tell their doctor how painful their periods are, in addition to wanting to contracept, and the proper diagnosis would be used to get it covered. It wouldn’t be lying because pain is subjective and whatever the patient says it is.

Sad isn’t it? People are up in arms about not covering ABC, when it really isn’t that hard to get them covered.

I went in for “heavy periods” and it took going to 3 different doctors to find one that didn’t want to just put me on ABC.

 

[Rence]

Yes, they are really set up that way. Unless they are self insured. I don’t know how those work, because I have not worked with those.
Sad isn’t it? People are up in arms about not covering ABC, when it really isn’t that hard to get them covered.

Well, I think you’re right. The computer can generate a payment or a code ‘not covered under plan’ depending on the diagnosis.

No, I don’t think it’s sad. It’s understandible, because women have trouble with certain pharmacists not filling their prescriptions because they won’t fill any ABCs and pharmacists do not have access (nor should they) to a diagnosis for the prescription written. Also, some employers won’t cover ABCs across the board, so if one is prescribed them for non-contraceptive purposes, they can’t get coverage either. And when you have insurance, but it won’t pay for a particular service, it’s hard to get help. It’s easier when you don’t have any insurance at all.

So, for example, if a woman is taking only the pill or a few medications with it, they can tell the pharmacist that they don’t have insurance at all, and get a discount, and that discount may be more economical than actually using insurance. But if they have a few prescriptions that are costly, it may not be that economical to pay out of pocket with a discount, and they may have to use their insurance to pay for the other prescriptions, and then pay full price for the pill. So I can understand them fighting for the mandate.

It’s all a matter of perspective. And yes, it’s very easy to get a prescription for the pill. And yes, they’re as available as skittles. If you have no insurance, they’re cheap as skittles. But if you have insurance, and your insurance doesn’t cover it, and your pharmacist knows that you have insurance that doesn’t cover it, you’ll pay full price because the computer won’t separate it out. But I guess you could present that one presciption to another pharmacy and not use your insurance card. It’s all a pain in the rear IMOHO…people are going to have what they want, and the more one tries to deny them, the harder they will work to get it.

My mom gets two of her prescriptions as samples from the doctor’s office. When she’s not in a donut hole, the prescriptions cost $50 each. When she’s in a donut hole, the prescriptions cost $145 each. So the samples really really help, and we can get them almost all year. I don’t know how available ABCs are as samples from the doctor’s office though, I’ve never had to buy them.

 

[maryjk]

Well, I think you’re right. The computer can generate a payment or a code ‘not covered under plan’ depending on the diagnosis.

No, I don’t think it’s sad. It’s understandable, because women have trouble with certain pharmacists not filling their prescriptions because they won’t fill any ABCs and pharmacists do not have access (nor should they) to a diagnosis for the prescription written. Also, some employers won’t cover ABCs across the board, so if one is prescribed them for non-contraceptive purposes, they can’t get coverage either. And when you have insurance, but it won’t pay for a particular service, it’s hard to get help. It’s easier when you don’t have any insurance at all.

All you have to do is opt out of your insurance for that prescription.

So, for example, if a woman is taking only the pill or a few medications with it, they can tell the pharmacist that they don’t have insurance at all, and get a discount, and that discount may be more economical than actually using insurance. But if they have a few prescriptions that are costly, it may not be that economical to pay out of pocket with a discount, and they may have to use their insurance to pay for the other prescriptions, and then pay full price for the pill. So I can understand them fighting for the mandate.

It doesn’t work that way. I have a prescription that my insurance would charge $90 a month. It is not generic and not on their formulary. So I had it run through without my insurance. It cost me $18.

It’s all a matter of perspective. And yes, it’s very easy to get a prescription for the pill. And yes, they’re as available as skittles. If you have no insurance, they’re cheap as skittles. But if you have insurance, and your insurance doesn’t cover it, and your pharmacist knows that you have insurance that doesn’t cover it, you’ll pay full price because the computer won’t separate it out. But I guess you could present that one presciption to another pharmacy and not use your insurance card. It’s all a pain in the rear IMOHO…people are going to have what they want, and the more one tries to deny them, the harder they will work to get it.

If this is happening to you, I would change pharmacies. I regularly have them run it through with and without insurance to see which is cheaper.

My mom gets two of her prescriptions as samples from the doctor’s office. When she’s not in a donut hole, the prescriptions cost $50 each. When she’s in a donut hole, the prescriptions cost $145 each. So the samples really really help, and we can get them almost all year. I don’t know how available ABCs are as samples from the doctor’s office though, I’ve never had to buy them.

Now there may not be a cheaper way to get a drug. My husband was on one that was $90 a month, but was hundreds without insurance. There just wasn’t any way around it.

 

[Rence]

All you have to do is opt out of your insurance for that prescription.It doesn’t work that way. I have a prescription that my insurance would charge $90 a month. It is not generic and not on their formulary. So I had it run through without my insurance. It cost me $18.If this is happening to you, I would change pharmacies. I regularly have them run it through with and without insurance to see which is cheaper.
Now there may not be a cheaper way to get a drug. My husband was on one that was $90 a month, but was hundreds without insurance. There just wasn’t any way around it.

Yeah, my insurance did that to me (or pharmacy, or whoever did it). If I used my drug card for my prescriptions, I had to use them for all of them. But I could go to another pharmacy for that one presciption, and not use my card, because they didn’t have my insurance information on file. I do not know if it was a pharmacy policy or an insurance policy. However, that was then. I now have a job that makes me go to a specific pharmacy only. I haven’t tried to see what would happen if I went elsewhere, but I don’t have a reason to now. Thanks for the tips I may need them in the future!

 

[pnewton]

This sounds like a logistics issue that should be easily solvable. Provide coverage for illness and injury. Provide coverage for a narrowly delineated regime of well-care. If hormones are given, it has to be in conjuection with treating an illness, not as care for a healthy woman. The employer should never be in the medical loop.

 

[Newbie2]

I agree.

Surely there are doctors who purposefully use a medical code or falsify medical records in order to get their patients BC for the purpose of BC under the guise of treating another type of medical condition responsive to BC drugs.

However, the employer should not as well have or even be allowed to be a medical cop.

 

[Rence]

I agree.

Surely there are doctors who purposefully use a medical code or falsify medical records in order to get their patients BC for the purpose of BC under the guise of treating another type of medical condition responsive to BC drugs.

However, the employer should not as well have or even be allowed to be a medical cop.

Don’t forget that pain is subjective. If a woman knows that painful periods can be treated with ABCs, she can tell her doctor how painful her periods are and that nothing works, and get the ABCs she desires that way. I wouldn’t blame it on the physician because pain is what the patient says it is. It’s not something that can be measured by anyone else but the patient.

I completely agree that the employer should never have anything to do with being or having medical cops.

 

[royal_archer]

I agree.

Surely there are doctors who purposefully use a medical code or falsify medical records in order to get their patients BC for the purpose of BC under the guise of treating another type of medical condition responsive to BC drugs.

However, the employer should not as well have or even be allowed to be a medical cop.

Normally I would agree that the empolyer has no business in the medical issues of the employee, but if you ask the employer to pay for a product normally used to facilitate a recreational activity they have the right to question it. I sell similarities between this and the medical pot issue. Should an employer be forced to buy their employees pot because some doctors prescribe it?

 

[Corki]

Correct. However, if the employer simply is deciding on if they want to purchase insurance that would cover this situation- the insurance co, would make determination of payment based on Dx code. The employers decision would be a general one for any employee they provide for who might be in that situation.if the employer provides insurance with that coverage, then the insurance co. would pay for it if the diagnosis code warranted that treatment.

I have never seen an insurance plan that did not cover drugs that were used for actual treatment of an illness. This assumes that the plan includes prescription drug coverage and that the drug in question is on the forumulary.

The whole issue for Catholic employers (and the crux of the HHS mandate) is classifying birth control as preventative medical care. There is a huge difference in how insurance companies cover treatment vs. preventative care. In the OP’s example, the drug would fall under treatment.

 

[maryjk]

I have never seen an insurance plan that did not cover drugs that were used for actual treatment of an illness. This assumes that the plan includes prescription drug coverage and that the drug in question is on the forumulary.

The whole issue for Catholic employers (and the crux of the HHS mandate) is classifying birth control as preventative medical care. There is a huge difference in how insurance companies cover treatment vs. preventative care. In the OP’s example, the drug would fall under treatment.

So how would they tell the difference at the pharmacy?

I have no idea how this works, but…

When I went to my third doctor, she is having me take hormones. I just take them a few days of the month, ten days in fact. My medication comes in a pill bottle and I have to count out from my period to figure out when to start taking them. My doctor did many blood tests to see which hormone I was missing and she has replaced that hormone.

My drug coverage, through my husband’s work, covers ABC. But my doctor is an NFP doctor only. So I wonder if it is the way the script is written and what is included in the script that makes it ABC or not.

 

[Corki]

So how would they tell the difference at the pharmacy?

I have no idea how this works, but…

When I went to my third doctor, she is having me take hormones. I just take them a few days of the month, ten days in fact. My medication comes in a pill bottle and I have to count out from my period to figure out when to start taking them. My doctor did many blood tests to see which hormone I was missing and she has replaced that hormone.

My drug coverage, through my husband’s work, covers ABC. But my doctor is an NFP doctor only. So I wonder if it is the way the script is written and what is included in the script that makes it ABC or not.

Most pharmacies these days are connected directly with the insurer via computer. If the prescription is entered into the computer, the insurer will either approve or deny coverage based on what the physician has already entered on his/her end. They don’t need to offer an explanation to the pharmcist.

If the pharmacy is not computer-connected, it will sort out when they seek reimbursement from the insurance company.