Treatment. Yeah, that’s been interesting. My insurance company denied the PA for me to continue with a medicine that has worked quite well for five years.  I am appealing.  Meanwhile, my doctor’s office has provided samples.  It’s a little weird to be handed $7K worth of medicine samples to tide me over during the appeal process.

The summer has been crazy.  Those whose blogs I subscribe to have filled my inbox with updated posts, but I have rarely clicked through to comment (although I mean to).

My two younger sons continue to participate in sports. This involved 83 events in May and June, plus practices. In July I collapsed from exhaustion — which I count as a victory. In the months before my diagnosis, I pretty much had to be home by noon because I was wiped out by then. Keeping on the go like I did is a testament to the effectiveness of my treatment.  When I was first diagnosed, there is no way my kids could have participated in sports.  Now they can.

In addition to all the sports, spring saw my older daughter fundraising.  She left the country July 1 for a training program to do medical missions work. She will go to Kolkata next and will spend two months in India, followed by one month in Bangladesh.  She is scheduled to be home for Christmas.

My younger daughter leaves next week for college. She’s planning to earn an exercise science degree and then apply to grad school to become a physical therapist.  We’ve been doing all the normal stuff one does to get a child ready to leave for college.

My oldest is about to begin his senior year of college (still a 4.0 engineering student).  He had an internship in Houston over the summer, but called one weekend and said that Christmas was too far away; he wanted to come for a weekend visit.  On that visit, he brought a very nice young lady for us to meet. Guess my kids are growing up.

We will be down to only two kids in the house this fall. The older one has developed an intense weight training workout and spent a couple hundred dollars of his own hard-earned money on some basketball skill-drills in an effort to improve his game.  Both boys are playing sports this fall before basketball begins in winter, too.  Fortunately the older one got his driver’s license over the summer, so I won’t have quite so many chauffeuring duties.

I saw my rheumatologist, and she is ambivalent about my official diagnosis.  Despite the dermatologist’s report, she sees no reason to switch my diagnosis from RA to PsA.  Her philosophy is that my diagnosis can be whatever will get my medicine approved by insurance, and it doesn’t really matter what label is used.

In the beginning, when I first was referred to rheum, I had follow-up appointments every two months.  In time, those follow-ups have gotten further and further apart.  Now I don’t have to go back for six months.  There was a time that I would have been appalled at seeing a doctor twice a year.  Now I’m thrilled that it’s only two instead of six.  It’s amazing how perspective can change.

Oh, the aggravation!

Changing insurance is every bit as frustrating as changing doctors.  My plan, unlike many, does not renew at the turn of the new year.  Dutifully I contacted the new insurer to make sure there would not be any problems filling my prescriptions at the pharmacy.  If prior authorizations were needed, I wanted to make sure all the paperwork got done in a timely manner.

What a pleasant surprise to hear that none of my meds would need a PA.  That turned to disaster when I actually went to the pharmacy and was told that they couldn’t fill the prescription because it did require a pre-auth.

My pharmacist is wonderful and goes above and beyond, fighting for her patients.  She phoned my insurance company and was told that they had no record of my calling them.  Really?  I’d called them three times by that point.  I immediately stepped away from the counter and called the insurance company myself.  Why on earth would they tell my pharmacist that I’m a liar?  Turns out that since I phoned before the policy took effect, their computer would not allow them to document anything.  While I was trying to figure out 1) why they had no record of my call, and 2) why they told me I didn’t need a PA if I really did, my pharmacist managed to talk the insurer into a one-time override so that I could continue taking my medicine while they processed the paperwork.  Words cannot describe my gratitude.

Fast forward one month.  I return to the pharmacy to refill all my prescriptions. They have not heard back from the insurance company so they can’t fill my cimzia.  Returning home sans biologic, I emailed my doctor’s office to find out when they sent my insurer the required information.  Monday morning, I then contacted my insurer to find out how long they take to process the paperwork.  They claim that they haven’t received any information. None.  Now, my last insurer tried that, but my doctor’s office was able to show me their fax confirmation which made the insurer magically find the paperwork after all.  Not this time.  Four hours later the head nurse called me back (I don’t think she’s even in my doctor’s office – hospital systems are so frustrating).  She apologized and has no idea why nobody had done the paperwork.  It’s not like it should take hours of sifting through chart notes.  All they have to do is copy information off the form that was submitted to my last insurance company!

After a long talk with the nurse, it turns out that whoever in my doctor’s office was supposed to take care of the pre-auth paperwork is in trouble.  The head nurse promised to fill out my paperwork herself today and fax it to the insurer, as well as phone both the insurance company and the pharmacy to try to grease the wheels and make things happen faster. I’m not sure what good it does to phone the pharmacy because they can’t fill the prescription until the pre-auth shows up (unless I pay cash, which I’ve done with less expensive meds, but I can’t do that with a biologic).

I can understand pre-auth paperwork taking a day or two.  If it were my job to process it, I wouldn’t drop everything to turn the paperwork around immediately. I’d probably collect all the requests in a folder and sit down to do them at the end of the day.  It wouldn’t take long, though, because I would have the information ready.  Think about it.  When the doctor first prescribes a biologic, or when a decision is made to switch to a different one, it is assumed that a pre-auth will be required.  Insurers don’t ask for your shoe size or other irrelevant info.  They want to know what meds have already been tried. They want dates.  They want proof that $50 meds don’t work before they pony up thousands of dollars.  Patients’ files already have a list of the date each med was started (and stopped).  Although it’s probably a hassle to complete paperwork for the insurance companies, it’s not difficult.  A high school dropout should be able to do it.  What I can’t understand is why, in a full month, nobody in my rheumy’s office managed to get the paperwork done so that I can get my medicine.

Okay, I take that back.  New plan.  If it were my job to do pre-auth paperwork, when the doctor wrote the prescription, I’d look at the patient’s chart to determine their insurance company, then grab the appropriate form and explain that due to the cost of the med, the insurance company would require extra paperwork.  I’d print the patient’s Rx history and task the patient with filling out the PA form.

There are a variety of ways to expedite the paperwork.  I don’t think it should take a month. I don’t think it should require the patient to place multiple calls and spend two hours on the phone.  I sincerely hope that the head nurse is able to inspire my doctor’s staff to handle things in a more timely manner.  If not, I won’t wait until retirement to go elsewhere.  I like my doctor, but incompetent staff just might drive me to find a new doctor.

Dry Eyes

eye drops 014One can spend a small fortune on eye drops.  Who knew there were so many options?

It turns out that there are (at least) two factors affecting eye lubrication.  First is tear production volume.  Eyes need to produce tears to moisten the eye.  If few tears are produced, then there isn’t enough moisture and the eyes will feel dry.  The second factor is evaporation rate.  If tears evaporate quickly, the eyes will be dryer than if tears evaporate slowly.

Regardless of the cause, when eyes are dry, they need to be moistened.

Artificial tears are available over the counter (OTC).  These liquid eye drops come in many brands, with different types available within each brand.  Plain artificial tears are what you want.  Drops for relief of red eyes usually contain an antihistamine, which is great for allergy sufferers but bad for dry eyes.  Note that bottles of eye drops contain preservatives.  In general, the recommendation is that if you use drops more than four times a day, switch to drops without preservatives.  Drops without preservatives come in tiny single-use applicators.  Whether it’s single-use tubes or full-size bottles, carrying them in your pants pocket all day 1) keeps them conveniently close at hand, and 2) keeps the drops warm, making them much more comfortable to put in.

Gels are also available OTC.  These are thicker than drops.  The advantage is that they don’t evaporate as quickly, so don’t need to be used as frequently as artificial tears.  One disadvantage is that they’re goopy, so cloud the vision for a short time after application.  For this reason, gels are usually used at bedtime.  Or, if you’re like me, you don’t mind enduring ten minutes of cloudy vision so that you don’t need to use drops quite so often.

Ointments are basically sterile Vaseline in a small eye-applicator tube.  These, too, are available OTC, and cost about $16 if you take one of the brands off the shelf.  My pharmacist has a $4 brand behind the counter.  Horrible as it might sound to put Vaseline in your eye, when your eyes are dry enough and you’re waking multiple times a night to use drops, you’ll try anything.  Ointments cloud your vision significantly more than gels, so if you try these, have everything ready so that  you can close your eyes and hop into bed immediately once the ointment is in.  You won’t even be able to see to find your way to bed, so if you can’t find your bed with your eyes closed, consider getting a mirror for your bedstand so that you can already be in bed when you put the ointment into your eyes.

Regardless of the amount of tears produced, sometimes those tears evaporate too quickly.  If the meibomian glands don’t work properly, the tears won’t contain enough oil to keep them from evaporating.  Sometimes these glands get clogged.  Applying a warm compress twice a day can help.  Although a hot washcloth can feel nice and relaxing, it won’t stay hot long enough.  One good option is a flexible microwavable heat pad.  This goes into the microwave for 25 seconds (approximately), and then will be the perfect temperature to place gently over the eyes for 10-15 minutes.  After this time is up, gently wash the eyes with warm soapy water.


A few other options for self-treating dry eyes:

  • Avoid antihistamines.  During the height of allergy season, this can be hard.  Allergy medicines are drying, though, so they will make dry eyes worse.
  • Avoid drafty air, fans, and air conditioners.  These tend to dry the air — and the eyes.
  • Seek out humid air.  Moist air can help the eyes retain their moisture.

If dry eyes persist, despite the best efforts of eye-drop manufacturers, make an appointment with your eye doctor.  This is not an appointment to have your vision checked to see if you need new glasses.  It will not be billed to your vision insurance, but to your medical insurance.  When you call, tell them that the reason for the appointment is “dry eyes.”  Take all your drops with you so that the doctor can see what you’ve tried.

When I saw my eye doctor, I led with, “My dermatologist says that my skin is dry. My dentist says that my mouth is dry. My eyes are so dry that I’m buying eye drops at Costco and emptying the bottles before they expire or get lost.  Can you tell me if this is Sjögren’s Syndrome, or something else that’s making my eyes so dry?”  Nope.  He couldn’t tell, but he could tell that I am both 1) not producing many tears, and 2) not producing much oil. Sometimes low tear production is due to inflammation, so I have $500 prescription eye drops that will take 6-8 weeks to take effect.  These are used every twelve hours, and are in addition to the preservative-free drops I need during the day and the ointment that I use at bedtime.

Wishing you pain-free days and nice, moist eyes.