THE BLOG
07/21/2010 12:47 pm ET Updated Nov 17, 2011

Beware - Health Insurance And The "Fine Print" UPDATE

Beware, insurance is something we think we know about. It's almost impossible to live in the modern world without it. Among its various definitions these elements stand out. Insurance is: "an act, measure or provision that gives protection." Or, insurance is: "a means of guaranteeing protection and safety." When needed, for reasons that require no further explanation, no insurance is more important than health insurance.

Most of us are also familiar with the - "fine print." It too has many definitions, but it has only one meaning: "something presented in a deliberately ambiguous or obscure manner." If the purpose of insurance is protection, the purpose of "fine print" is deception. For the insurance company, or other corporate interest, that simply means a method and process whereby they might reduce, limit or totally eliminate their liability to the so-called insured. Here's how it works.

1. The insurance company offers to protect you against something.
2. The insurance company charges money for that protection.
3. The insurance company does not provide protection because of the "fine print."

Some readers may know I had a heart transplant. To prevent my new heart from being rejected by my body's immune system - to stay alive following my heart transplant - I must take two powerful and very expensive immunosuppressant drugs. Together, they can cost as much as $35,000 a year. One of them is Cellcept, manufactured by Roche Pharmaceuticals. At my dosage level, Cellcept costs about $2,000 a month. While there are no guarantees Cellcept will work - after all, no drug is 100% effective for 100% of all patients - without it I stand no chance of survival. This medicine is a matter of life and death. The Roche brand name Cellcept has been very effective for me. However, the generic version was not. When I switched to it I showed organ rejection. After treatment to reverse the rejection I was put back on a "brand only" prescription.

As a financially responsible adult, I bought the proper insurance and even a secondary policy to take care of any possible uncovered expenses. My insurance covers Cellcept. No problem. I'm fine.

I get my prescriptions filled at a Publix Pharmacy. Publix is one of the biggest and most profitable supermarket chains in the United States. There are more than 800 Publix Pharmacies. They've done a fine job... until now. Publix just advised me that - starting in August - they will refuse to fill my "brand only" Cellcept prescription. They took this position because Publix has been getting a "rebate" a "discount" or what some might call a "kickback" from Roche on my Cellcept prescriptions - in addition to the insurance reimbursement - and that extra payment from Roche is ending. So, Publix told me they will only fill a generic prescription. But of course, I have no choice in this. I cannot use the generic. My doctors and my transplant center have specified that I must take the brand name Cellcept. Publix doesn't care about that. All they care about is the money from Roche they will no longer be getting.

Publix does not deny their decision is entirely based on the end of the Roche "kickback" program. I have spoken with their corporate Pharmacy Supervisor, Michael Poblet. He was polite, open and straightforward about this corporate policy. Poblet said, Publix will fill my brand name prescription only if I pay cash for the total amount. They will no longer recognize or accept my insurance.

Publix has a contract with my insurance company. They have agreed to a specific reimbursement for every Cellcept prescription they fill. No one forced Publix to sign this contract. They didn't have to if they weren't satisfied with the payments they were agreeing to accept. And, my insurance company was supposed to provide me with "protection" and "safety." Isn't that what I pay them for?

How then could I be denied both? No more "protection." No more "safety." I'm still paying my insurance premiums every month. Publix is still listed as a "participating pharmacy." What happened here? The answer, of course, can found in the "fine print."

Despite my faithful compliance and timely payment for my insurance coverage, my insurance never actually provided me with either "protection" or "safety." It's just a façade. You see, the "fine print" allows Publix to handpick those prescriptions they will fill and those they won't. They're not really a "participating pharmacy" and I'm not really insured. At the whim of Publix corporate executives, they can deny any prescription, as they have mine.

When I complained to my insurance company, they told me "to read the fine print." Of course, that part of the "fine print" was never available for my inspection. It was a private matter between my insurance company and Publix. It was their contract, not mine. It was the perfect arrangement - for them - because there was no way I could have known this might happen to me.

I have about another month's supply on hand. After that, although I pay my insurance company every month, and my doctors continue to prescribe the brand name Cellcept, I am left to fend for myself.

UPDATE: THE WAL-MART PHARMACY HAS AGREED TO FILL MY "BRAND ONLY" CELLCEPT PRESCRIPTION. THANKS TO ALL WHO HAVE ASKED.