Family Fighting Insurance Company Over Kids’ Medicine

By Melissa Newton, CBS 11 News

CROWLEY (CBSDFW.COM) – A North Texas family is in a very expensive fight with their insurance company over the medical needs of their children.

Right now, Ricky and Sharon Free are paying $1,400 a month out-of-pocket, but the medicine was fully covered just three months ago.

The Free’s have four adopted children.  All of them have been diagnosed with Attention Deficit Hyperactivity Disorder, ADHD, and take various prescriptions to control it.

“They’ve been on this medication for years,” said mother Sharon Free, “we’ve had no problem getting this medication in the past.”

In January, Ricky’s employer switched from Blue Cross Blue Shield of Texas to United Healthcare and Ricky said United will only cover 31 pills a month per child, even though the family’s primary care physician, Dr. Mike White, determined two of the kids need much higher doses.

“It’s unfortunate that they have to take that high of a dose,” Dr. White said, “but this big dose works.”

“Their ADHD medicine is key to their day-to-day functionality,” Sharon Free said. “We’re going into debt because we can’t afford the medication, but we can’t afford to take our children off the medication.”

“It definitely will impact what we will be able to accomplish as a family this year if it isn’t rectified,” Ricky added.

The family’s case is far from isolated. Dr. White said other patients are having similar complaints.

“Their insurance plan has a pill limit per month. It doesn’t matter what dosage the child is on or how many months or years they’ve taken it, all of a sudden they’re limited on the number of pills that they can have,” he said, “It’s going to happen more and more.”

Kim Whitaker, a spokesperson for United Healthcare, said the company is looking into the Free’s case, and emailed a company statement Friday afternoon:

“Based on our initial review of the Free’s appeal, the prescription dosage is double the maximum recommended by the FDA for Shelby and four times the maximum dosage for Ryan. Because these dosages exceed FDA guidelines for these particular medications, additional clinical reviews are necessary. We will continue to work with the family to reach a conclusion.”

“I think it should be illegal or something for some person who is sitting in a building somewhere to deny a child medication when they have no clue why this child needs this type of medication,” Sharon said. “It’s infuriating.”

The Free’s worry if United leaves them hanging, their kids will be the ones who lose the most.

State Representative Bill Zedler of Arlington and the Texas Department of Insurance are both looking into the family’s situation.


One Comment

  1. Donna Heil says:

    I was diagnosed with narcolepsy & delayed sleep phase syndrome a couple of years ago. The 2 disorders have devastated & disrupted my life for as long as I can remember. My neurologist prescribed Xyrem, which is available from 1 pharmacy only since it’s GHB in its purest form & is strictly controlled. And expensive. The dosage I was on was the max so the cost of it was about $2,000.00/month. My copay was $25.00 (ironically, with UHC). For the first time in 40+ years, I was sleeping. I was beyond functional. My blood pressure normalized. My diabetes was under control. I was healthy, happy and rested. Until my company switched to Humana. My copay went from $25.00/month to $500.00/month. And all I had to do was pay that $500/month for 7 months & then I’d have met the deductible and the last 5 months would be “free.” But that deductible was a completely different one than the policy deductible so I’d have to meet that amount as well. We could probably have managed but it would have been a tight squeeze. Whatever. This was an insult added to injury since the cost of insuring my self employed husband on the new policy was more than doubled so I had to drop him from my policy. My coverage only went up $25/month. But every co-pay went up. For the 1st time, I see OB/GYN’s under the specialist co-pay after years of being classified as a primary care Dr since women needed to have access to that care. The co-pays on all my medications went up. And I can’t tell you how many refusals for new prescriptions I’ve seen. It seems that Humana’s pharmacist knows better than my amazing Dr. what I need. Funny, it’s always the expensive drugs they determine aren’t right for me. He could prescribe dog meds for me and as long as they were cheap, they’d approve it. But you get smart after awhile. If you study your policy, they make a big deal about preventative versus diagnostic. If a test or procedure was labeled preventative by the Dr, it was generally 100% covered. Diagnostic, on the other hand, had a much higher copay. Seems to me that an insurance company would want a possibly life threatening condition diagnosed. But I guess it’s cheaper to let it go undiagnosed, let them die and get them off the policy. All that being said, without the insurance company, even with the higher everything, I wouldn’t be able to afford the type of care and meds they help provide. Someone has to fix this. Drug and insurance companies seem to own a lot of lawmakers based on what they’re allowed to do. If the people who make these laws were forced to live by all of the rules and laws that they put in place for all of us common folk, I think we’d be seeing a much fairer system. Same with Social Security and Medicare…if they didn’t have that pot of gold at the end of the political career to fall back on…SS and Medicare would be completely solvent and easy to understand. I just want it to be fair. The government could do that if they really wanted to but there are too many interests being protected…none of them ours. Very sad.

  2. Kevin says:

    So all 4 kids just happen to be diagnosed with the same exact “disease?” Very interesting. Then you have a doctor that is overmedicating 2 of them, according to FDA guidelines and recommendations for that very medication. CPS needs to get involved here quick.

    1. jmwdoc says:

      I think you have a wrong assumption here. The fda guidelines are just that , the ideal, however sometimes a patient requires a larger dose based on symptoms or functionality. A good example might be the management of diabetes. If the bs is elevated but max dose of suggested insulin is reached, then there are two ways to proceed either increase the insulin dose above the guidelines or add additional medication (or adjust diet/exercise etc). Some patients just do not fit the usual mold for management of a disorder and with careful monitoring and adjustment one can slowly increase the dose SAFELY until the desired outcome is acheived. I hope this helps your understanding.

  3. insurancesucks says:

    Sounds like United Healthcare is trying to practice medicine.

Comments are closed.

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