Should I try to bill my asthma medicationto my insurance company, or will they fire me for a prexisting condition?...

May 15, 2006 6:24 PM

Hi. I recently (about six months ago) switched health insurance providers. I filled out the application form honestly, except for one thing: I forgot to note that I'd received a prescription two years ago for an albuterol inhaler (which is an inexpensive inhaler used to relieve asthma attacks while they're occuring.)

At that time, the inhaler was all I needed - I was having infrequent moments of wheezing during intense exercise, and never any other time. My doctor thought having it would be a good safety precaution, and I did end up using it. I also billed the inhaler to my own insurance (which was, in retrospect, probably not so smart, since it only costs about $15 retail.) I never refilled the prescription.

So, when I got my new insurance, I just forgot about the inhaler, since I hadn't used it in almost two years.

Last week, I started having major breathing problems - not just during exercise, but also while sleeping, and throughout the day. My doctor wants to "calm" the episode by putting me on Singulair and the Advair discus. Retail for these meds are about $300, total, for a month's supply.

I was going to put them on my insurance, but I have heard horror stories about companies retroactively cancelling a policy based on failing to reveal a pre-existing condition. Inadvertant as it was, I am clearly guilty of that - though my "pre-existing" condition was a fairly minor variant of it.

I know that insurance companies are not very forgiving. My question is whether I should just pay for the drugs (which cost more than my insurance premium) and hope that once my condition is calmed, I won't need them routinely. My doctor doesn't know how long I could or should be on them; if it turns out to be a chronic thing, then is it wise for me to file a claim - now, later, or ever? If later, then how much later?

(I don't think, btw, there's any way for my insurance company to know that I was using the inhaler back then - I shop at a different drug store, and my doctor has told me that she won't release any past records, if my company asks, and only what's neccessary to support the current diagnosis.)

I know that there are behavioral and lifestyle ways to control asthma, as well. I would like to look into those, so if anyone has advice on that - stuff that really works, please! :) - I'd be grateful, as well.

thanks!

posted by soulbarn to health (13 comments total)

Is this a group policy for some large organization? Have they negotiated rates for doctors, pharmacies etc in which case the actual cost to them for your meds will be a lot less than retail?

All in all, I wouldn't worry. Don't mention a thing. Just submit the bill as usual. This is why you have insurance.

Getting a single prescription for an inhaler two years ago isn't much different than getting a single prescription for muscle relaxers if you hurt your back, IMHO.
posted by bim at 6:40 PM on May 15, 2006

I've been in the same exact position for a very similar prescription (had breathing problems and got prescribed albuterol), got it covered with my then present health insurance and i never disclosed it with my new insurance and have used the new insurance to get prescriptions for this 'pre-existing condition'. It was never an issue for me and I trust it wouldn't be for you.
posted by ibechase at 6:45 PM on May 15, 2006

I doubt you can be fired for this, or even loose your insurance. Many (all?) insurers have a "pre-existing condition exclusionary period," typically 12 months, where they will not cover pre-existing conditions. However, if you have previously had health insurance you can get a "certificate of creditable coverage" which can reduce or even eliminate the exclusionary period altogether.

I suggest you review the particulars of your health insurance, with an eye to the terms in quotes above. You might also want to try googling the terms hipaa and "pre-existing condition."

I know this because I'm presently in a similar situation. Good luck, and best wishes.
posted by funkbrain at 6:51 PM on May 15, 2006

You had exercise induced wheezing, in remission, and you forgot to note it. You now have asthma, a very common illness, different from that which you had previously, and it needs to be treated.

Just let your insurance do its thing. If they dropped you over this, which they won't, you would have cause to celebrate, because they would just have made you and your attorney very rich.

In reality, they'll be happy to swallow the cost of advair discus and singulair, because even years and years of this therapy is cheaper than one ambulance ride and E/R visit for asthma exacerbation.
posted by ikkyu2 at 7:20 PM on May 15, 2006

Your insurance company almost certainly can discover that you had a scrip for that inhaler, btw; insurance companies and pharmacies maintain giant databases of prescriptions and diagnoses. Neither your consent nor your physician's cooperation is required, and you may not opt out.

That said, I stick by my opinion that this is no big deal and your insurance company will almost surely cover the new med.
posted by ikkyu2 at 7:22 PM on May 15, 2006

Yeah, make the insurance pay for the meds. Even after they pay the $300, they're still coming out ahead. You can honestly tell them that you never were told you had asthma, if it ever comes up. Albuterol is sometimes prescribed for people suffering from acute bronchitis, which almost all of us have had at some point. Your doctor cannot legally release records from another doctor to a third party, even with your permission. The insurance company has to specifically ask for the records from your original doctor, if they even have a way of finding out who it is.

(The fact that the current insurance mess makes normal people like you, with normal medical problems think twice about filling their prescriptions just makes me seethe.)
posted by Slarty Bartfast at 7:42 PM on May 15, 2006

I wouldn't even characterize it as a pre-existing condition. You've developed adult-onset asthma (AOA) just as I did, when I was 35. You definitely want your insurance to be paying for the meds (for as much as they'll cover) since you'll probably need them for the rest of your life. Welcome to the club!
posted by Rash at 8:49 PM on May 15, 2006

get your drugs. Use your insurance. If you're freaking out, ask your doctor if he's got samples. Also, didn't you just see your doc for your recent asthma problem? Did you use your insurance for that visit? If so, when your doctor billed your insurance, it was coded with your main complaint (i.e. the insurance will know you saw him for asthma, if that was the main diagnosis he gave you). If that visit already went through & was paid for by your insurance, then you have confirmation that it's fine by them. And even if that hasn't happened yet, I'll bet dollars to donuts that you'll be fine. I don't see how your situation qualifies as a preexisting condition.

preexisting condition=a condition you got treatment or saw a doctor about in the 6 months before your enrollment date in your new insurance. (see sec 9801.a.1 of hipaa, and also under California law) Your saw the doctor & got the albuterol two years ago--even if he coded your diagnosis when you saw him as "asthma," which he probably didn't, you'd be in the clear since you haven't sought treatment in the last two years.

And even if you had a preexisting condition (which you don't), the longest the exclusion period can last is a year under normal circumstances. And if you had health insurance coverage before (& you didn't have a break of over 63 days without coverage), subtract however long you had that insurance away from the 12 month exclusion period--that's how long your new reduced preexisting exclusion period is.

p.s. insurance companies suck.
posted by neda at 8:55 PM on May 15, 2006

I agree with the others, but as I recall, the cost of an albuterol inhaler at the Costco pharmacy is less than my copay.
posted by Good Brain at 9:02 PM on May 15, 2006

How To Good-Bye Asthma: If You Infect Yourself With Hookworms. Malarkey? Or Effective Way?
posted by evariste at 11:10 PM on May 15, 2006

Get an asthma diagnosis from your current doc, and carry on as normal. Nothing unusual about that. Stressing will only make your asthma worse. ;)

I'll second Good Brain's advice on albuterol, too; I know your doc is prescribing Singulair and Advair (unusual to see both unless your lung function tests showed a severe condition that didn't respond well to albuterol -- may be worth seeing an allergist here, as they tend to have more experience with asthmatics), so bill those to your insurance. But albuterol can be had in generic form for less than some insurance co-pays for generics.

Remember: Take that purple turtle just like the doc says, and the Singular before bed (probably what he said there, too). You probably won't need the rescue inhaler at all if you're diligent about the other meds. And go see an allergist! It's a leading cause of asthma, even adult-onset.
posted by Merdryn at 6:13 AM on May 16, 2006

This is no big deal. And you weren't diagnosed with asthma, so it's not a preexisting condition.
posted by desuetude at 8:14 AM on May 16, 2006

You have a lot of speculation above, with very little actual facts. neda has given you the best advice. Get your drugs. Use your insurance.

Insurance companies will screw you for very many reasons, but simply using your benefits is not among them. Your fears are based on a situation like this: I am uninsured, and have been for more than three months. All of a sudden, I get sick and go the doctor, who tells me I have pneumonia. I nod, pay cash, and then go out and shop around for insurance, neglecting to tell anyone I have pneumonia. I get insurance and then go back to the clinic and try to get treatment. Sorry, not covered. Insurance is a hedge against the possibility of future problems, and they don't appreciate you gaming the system.

If, however, you are more or less continuously insured, then you are playing by the rules. What's covered is covered, within the constraints outlined by neda.
posted by deadfather at 10:17 AM on May 16, 2006