We face a potentially serious medication problem

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We have a potentially very serious medication issue with Gavin. Today  we received another denial letter from his insurance company. This time it was about his antipsychotic medication, Clozapine. They are refusing to pay for his prescription because his dosage is higher than the FDA approved amount. 

I’m not sure how we are going to address this. 

The only reason this is even an issue is because Ohio has forced everyone on disability, to choose an HMO provider and transition  from straight Medicaid.

What we need to find out, is whether or not this denial was sent before or after the attempt at a medical override.

This is a very serious problem because Gavin has less than a days worth this medication left. If this gets messed up, it’s a really, really bad thing. The biggest problem is that if the Clozapine stops working, we have nothing left to treat his Schizoaffective Disorder.

My priority for Wednesday is to get this straightened out before anything gets worse.

I’ll be very honest with you and say that I’m pretty nervous about this.  We have to get this fixed tomorrow, we have to. 


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Rob Gorski

Full time, work from home single Dad to my 3 amazing boys. Oh...and creator fo this blog. :-)
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Gilda M Sanchez

Gosh Rob, the reason for their concern is this: “safety and efficacy of Clozapine is not established for pediatric use.” The black box warnings are scary. I would suggest to his psychiatrist an alternative Dopamine blocker?

Missy Plenge

🙁 I sure hope they get it fixed for you very quickly.


I didn’t mean that to sound harsh.  Gov Kasich probably has some great points as well.  It’s just that there are predictable outcomes from cost-cutting schemes.  It’s terrible that you are on the receiving end of those schemes, that’s all.


This is the direct fall-out from the movement by Repulican governors (led by your Gov Kasich) to cut Medicaid costs:
“If the federal government would give us the flexibility to manage Medicaid, and that doesn’t mean spend federal dollars on highway projects, like they were doing 15 or 20 years ago, but give us the ability to manage Medicaid, I have no doubt that we would cover more people at a lower price with a better quality outcome,” Kasich said.  (12/2011)
They got that “flexibility” and the result is what you are experiencing now.  It’s a pity, truly a pity.


The insurance companies will look for any excuse to deny coverage and save themselves a few $$$.


You can appeal even if the provider attempted to call in the prior auth- that being said, as a medicaid nurse insurance coordinator, 9 times out of 10, the office hasn’t called it in.  Not a doctor issue so much as an administrative one.  I will keep my fingers crossed that this is the case for Gavin.  As always, thoughts and prayers.

Devin Smith

That’s not good. You can’t mess around with those meds. I hope you get it resolved asap

Caroline Benbrook

Good luck to getting everything resolved, insurance companies don’t take into account the lives that are affected 🙁