I pit Blue Cross and various pharmacies for not knowing their ass from a hole in the wall

I’m even sure who’s to blame.

I have a specialty injectable medication I take for GI problems. I’ve been taking it for years. It has to be shipped from a specialty pharmacy.

I’ve sometimes had problems with getting it filled in the past, so what I’m about to describe isn’t something new, although it’s on a whole new level of FUBAR this time.

On December 17, I called the specialty pharmacy because I only had a couple of weeks worth of medicine left. I had 9 refills left. They said they would okay it with my insurance and call me back about shipping.

A little while later they called me back and said that it required a new authorization and that they would be calling my doctor’s office.

This set off alarm bells in my head because I’ve had problems getting this medicine numerous times in the past. Several times I’ve ran into huge drawn out bureaucratic snafus when attempting to get this medicine.

The last several times, the broker that I get my insurance through has managed to quickly straighten it out (they serve as a healthcare advocate). One woman in particular has always been extremely good at straightening things out. So I immediately sent off an email to her explaining the situation. A while late I got a response from a different person saying that she was no longer with the company but they’d be happy to help me. They said that they would contact the doctor’s office to make sure that the proper authorization was sent.

Over the next couple of weeks I went back and forth between the broker, the pharmacy, and the doctor’s office. The pharmacy repeatedly told me that they had not received the authorization while the doctor’s office repeatedly told me that they had sent it. This dragged out for so long partly because that time period spanned two long holiday weekends.

Finally, the broker found what was apparently the problem. The pharmacy was sending the doctor the wrong fax number when asking for the authorization. She said she had given the correct number to the doctor’s office and that they said that they would take care of it.

So then the doctor’s office sent the authorization to the proper number… I think.

The pharmacy then, after days of this, realized that “Oh hey, we don’t ship that medication any more, you have to contact the insurance company to find out who does”. Why didn’t they realize that right away, and why didn’t Blue Cross tell them that when they asked for authorization?

So then the question was, where do I get the medicine from? The broker, after checking with BC, told me that I could get it filled at my local pharmacy. I was skeptical but I figured fine, I’ll call them.

I called my local CVS, which I use regularly for other prescriptions, and explained the situation. I also explained that it was a specialty medication that they would have to order. They told me to call the other pharmacy and have them transfer the prescription to them.

I did so and a while later CVS called and said that they could not order that particular medication and that they would transfer the prescription back to the original pharmacy.

After throwing things around and kicking things for a while I managed to calm down… I emailed the broker and explained the situation. She said that she would look into it and get back to me. That was yesterday. Last night, around 7:00 (she actually worked overtime on this) she called and said that it should be ordered from CVS specialty mail order pharmacy. This sounded right to me because this was the pharmacy BC used to have me use before switching me to Acro. The broker told me that I would be contacted in the morning by a gentleman (presumably from CVS) to arrange things.

This morning, no one called, so I emailed the broker. She said that she would look into it. Around 5:00 this evening she finally got back to me. She asked me if the type I used was LAR (long acting release) or not. My first response was something like “they have the freaking prescription, can’t they read it? No, it is not LAR”. She then said that if it was LAR then it would be direct ship, otherwise I should just get a prescription and take it to my local pharmacy. :confused::eek:

I explained to her that I had already tried that per her colleague’s instructions and that they were unable to order it. She said that she will look into it in the morning.

So I tried to get a refill in plenty of time. Now I’m down to a tiny bit at the bottom of the bottle. I normally titrate the amount I take based on symptoms, so I’ve been rationing it and suffering somewhat in an attempt to not run out completely. As a result I’ve been feeling poorly for the last few days, I’m eating nothing but things like yogurt, jello, and poached eggs, and I’ve lost 6 pounds, probably due to fluid loss.

And at this point I have little hope that this will be resovled tomorrow and the weekend is approaching.

I think I may call CVS Specialty Pharmacy and see if they can get the prescription and sell me one vial that I’ll pay for out of pocket.

This is fucking ridiculous. I am at my wit’s end.

Egad - what a nightmare.

I’d suggest reporting BlueX and the various pharmacies to whatever regulatory agencies control this sort of thing where you are (state insurance commissioner, for a start).

My mother-in-law was on a course of specialty medication for her multiple myeloma - and had trouble getting it shipped in time. I had to get an injectable joint fluid (like Synvisc, but another brand) and it took well over a month. The specialty pharmacy claimed the orthopedist’s office wasn’t answering the phone when they tried to call to coordinate it. This was pure bullshit, as I’ve never had trouble reaching that office.

It’s just completely ridiculous. I can’t quite say I fell your pain because in my situation it was less urgent - though in my MIL’s case, it was life-threatening.

Try Goodrx - my $350/mo sleeper was $20/mo with the Goodrx coupon.

See if they have a discount on your drug.

I fucking hate pharmacies. I quite like some individual pharmacists, but I fucking hate pharmacies. I have to deal with this bullshit for some 20 different patients at a time. It’s a constant war of finger pointing. “We didn’t get the authorization back from the doctor’s office!” “We didn’t get a request from the pharmacy!” or “We faxed it back already!”

I currently have a family pissed off at me because I didn’t call the pharmacy for refills “soon enough”, when I called them two weeks before he was due to run out. I called them three times that week (the week of Christmas, joy) and twice the next. They went several rounds with the doctor’s office (who I also called four times) finally got everything authorized and promised to deliver them last Wednesday and then their driver decided he didn’t really have to deliver them when promised, and so the patient went two days without his medications over the weekend. When, of course, the pharmacy was closed because of the holiday weekend after NYE. And this is all my fault.

Fuck. Guess I’m finger pointing too, but I really don’t know what more I could have done.

And it’s not like that particular pharmacy is particularly bad. They all do it. So I can’t even suggest they switch pharmacies (again) because I don’t know a single one that hasn’t pulled this shit on someone.

Fuck pharmacies.

Oops. My first sentence should have been “I’m not even sure who’s to blame”. Maybe a mod can fix it.

Honestly, I’m half considering hiring a lawyer or something. Maybe I’ll try the suggestion about contacting the state. I’m in PA. Anyone know who I would contact? I can probably Google it. This isn’t the first time I’ve had problems with this, but I think this is the worst. I think part of the problem is that the medication is not covered by my prescription plan, it’s covered under medical instead. I know that sometimes confuses the customer service reps at Blue Cross.

Of course that doesn’t solve my immediate problem.

I left retail pharmacy in 2002, and the profession altogether in 2012. This kind of thing is one of the reasons why. Every new year, and new fiscal year for Medicaid patients, was a nightmare. (This was prior to the implementation of Medicare Part D[isaster], about which one colleague said, “When that goes online, you will find out just how free it is.”)

Trust me, we pharmacists don’t want to tell you “no” any more than you want to hear it, and when I worked in retail pharmacy, helping people jump through hoops to get needed meds at an affordable price was probably the most rewarding aspect of my job.

Gads. Tony recently switched from a common opioid pain reliever (hydrocodone) to one I had never heard of at the time (Nucynta -sp?) The new medication works better for him, and doesn’t make him so loopy, but apparently, no one keeps it in stock. Fortunately, the pain management doctor has enough experience with treating Tony to trust him with a spare prescription - the scrips live in the safe, Tony generally uses about 20% less than standard safe dosage, he’s kind of the ideal patient for a pain management doctor. But the spare is so that we can start trying to refill early. It commonly requires a week or more, two or three pharmacies, and a call from the attorney to get the damned insurance company to approve the payment.

I have no idea what the difference is between the cost of the two medications - I assume that the new stuff is more. But Tony switched in an effort to avoid a surgical implant that costs a substantial amount (hundreds of thousands, according to all the research I’ve done, with no guarantee of success and a lot of documented complications.) You’d think, knowing that is on the table as the only next step available, that the insurance would be sending the new medication by concierge, instead of fighting the (guessing) $40 or $60 per month “extra” expense. But no…

(Come to think of it - if, conservatively, the insurer had to pay a quarter million for the surgical implant - device, hospital, surgeon, anesthesia, etc. - and assuming a reasonable 4% return on company assets, as long as the new medicine costs less than $833 per month and keeps Tony out of the operating room, it’s a good investment, right? )

But what do I know? I’m just talking about a human being here. The insurer is dealing with the important stuff, like a few extra bucks in the pocket of some company vice president. We all know that an executive needs a beach house AND a place in the mountains if he’s going to be accepted by his peers!

Okay. So I’m looking at GoodRX. Some of the prices are close to the deductible I normally pay for this stuff, but I’m skeptical. One of the pharmacies listed is CVS, which is the pharmacy that won’t order this medicine. Maybe I’ll call around tomorrow.

Wherever I get it, they will have to order it since it’s extremely unlikely that they’d stock it. So that probably means not getting it until after the weekend at this point.

Lacunae Matata, You mentioned a call from your attorney. What kind of attorney would I look for for something like this?

Of course, then I’d have attorney’s fees on top of everything else.

What really frustrates me is that the woman I used to deal with at the insurance brokers was always able to straighten things out pretty quickly, but now she’s gone. The people who are helping me now just don’t seem to be quite as knowledgeable as her.

Here’s the cost of Nucynta.

You have to get a LAWYER involved for your meds? :eek: :mad: First I’ve ever heard of that.

I’m considering it myself. I’m beyond frustrated.

Cool. (I assume that the insurance company has a lower negotiated price, but even at the full price quoted, Nucynta is significantly cheaper than the potential surgery, even without considering the follow up care.)

And the attorney is because Tony’s is a workman’s compensation case. We hired her when the insurance wankers quit approving necessary treatment and quit reimbursing mileage and refused to answer phone calls unless we accepted an insult of a settlement. Whatever she takes home from this case, she has earned.

Ugh, I’ve had a similar experience with my stuff. Self-injected arthritis medication that needs to be kept refrigerated and oh by the way costs as much as a 3rd world country’s GDP. Because of that last bit, the insurance company (every one of the several I’ve been with while taking this med) requires that I only get it from their specialty pharmacy. To the point where they yanked it away from the local retail pharmacy once after I had it filled there. There was no “hey, you need to transfer this”, it was just “we’ve moved your rx”!

Anyway, my beef is with the pharmacy management companies. Retail pharmacies can at least show compassion and give you a couple days worth of meds when you get into bureaucratic tangles. The management companies? Fuck no. When I got into this situation with my arthritis med one time a few years ago I actually had to go without my meds for over 6 weeks before it got all straightened out. Good thing it wasn’t heart medicine, eh?

The management companies just add more bureaucracy and are no help at all. All they care about is ensuring that you don’t spend a penny more than necessary on your meds… if you land in the hospital because you ran out of your meds… that’s someone else’s problem.

I decided that I had to take the bull by the horns because apparently my broker no longer has anyone competent to help me with this.

I spent all morning on the phone. First with Acro, then CVS Caremark Specialty, and finally with Blue Cross.

At least now I know the full story. They did receive the necessary authorization information from my doctor. The problem is finding a vendor to fill the prescription. The reason the other pharmacies were saying that there was no authorization was because BC won’t forward the authorization until they find a vendor that can supply it and apparently neither of them can. So BC is in the process of trying to find someone who can supply the drug.

So the problem isn’t with the authorization. The problem is with supply. That answer doesn’t help me, of course, but at least I now know what’s going on.

More confusion:
So I emailed the broker about this. She responded. She told me that what they’ve now told her is that the problem is that this medicine was never supposed to be direct shipped. If they were doing so it was mistakenly. (For over 10 years???)
At the same time, local pharmacies can’t order it. (WTF? They’ve been selling this stuff for a long time. Who was buying it and how?)

So now they’ve decided that they will ship it this one time, and they’re in the process of finding a supplier. But then they will have to decide how I will get it in the future.

None of this makes any sense whatsoever.

Sounds like a very specific/specialized medicine.

I would compile a list of vendors and keep give this information to your insurance and doctor’s office to avoid this hassle going forward.

They know who the vendors are. Any information I can access they certainly can. They just have to find one who has it available.

The thing I don’t understand is why they’re saying this never should have been available by direct ship. Who is more likely in error: the people who’ve been shipping it for 10 years or the people who’ve now decided that’s not allowed and never has been?

Yikes. Looks like you’re taking Unobtanium HCL.

(Possible side effects include anxiety attacks and migraine headaches from trying to find someone who stocks this medicine.)

Is it possible that the lab that makes it went out of business or something?

Any way to contact the manufacturer directly?