A few weeks ago I started a new job (hooray!), which of course has the downside of changing my medical insurance. I’ve been through this game before, so I know the drill: couple weeks to let the enrollment processing get done, a week or two to get my medications re-ordered from my doctor and the expensive one to be yanked away from my local pharmacy to the insurance plan’s specialty pharmacy, a week or two for their bureaucracy to work through, and viola! I’m overdue taking my med by 2-6 weeks (depending on how many BS delays there are). So, yes, I’m going through that again now.
I have a special pitting for pharmacy management companies. They claim they’re there to help patients get cost-effective care, but I’m convinced they’re there to save money by dragging their heels. But that’s a digression, today my beef is with my doctor’s office. The expensive medication in question is Enbrel, a refrigerated biologic that’s dosed in once a week injection.
I’m now 4 weeks overdue in taking my “next” dose because of the insurance change. I called the specialty pharmacy last Friday and they said they were waiting for clarification from my doctor. I tried asking them what they needed, and the lady just hemmed and hawed. I gave up and called my doctor’s office. They didn’t give me any clues either, but said they’d fax the rx again.
I called the pharmacy again today (Tuesday) and they were still “waiting for clarification”. This time I told the lady that I was 4 weeks overdue on my meds so I just wanted to facilitate this as best I could, so what exactly did they need. She said they needed to know the dosage, refill amount, etc. Typical info that’s on every prescription so in my head I was like “wut?” So I got their fax number and called the doctor’s office again.
As I was trying to explain the problem to the doctor’s office I realized what the problem might be. I speculated that they were faxing the rx to my local Wegman’s pharmacy instead of to CVS specialty pharmacy. She looked it up and confirmed that’s what they were doing. So I gave her the CVS specialty fax number, and I think - HOPE - the problem is solved.
But come on people… you’re a rheumatology doctor’s office, so you prescribe things like Enbrel on a daily basis, and you don’t KNOW that the insurance companies only fill it through their specialty pharmacies? Worse, you were not responding to them when they contacted you!? Asshats!
It’s not fun, that’s as much as I can say. It’s interesting that whenever I refill the Enbrel (schedule a shipment), one of the things they always ask is when my next dose is. There have been times (the ones like I describe above) when I’ve told them “4 weeks ago” and they say nothing about it but continue to the next question. So like, why did you ask?
Nobody gives a shit, clearly. Well, except the patient. He/she has a vested interest.
Specific to my case, what really worries me is that I’ve heard that Enbrel has a chance of not working for you anymore if you skip doses. I don’t know if that’s true. Nobody but fellow arthritis sufferers seem to worry about it.
That just seems strange. What if someone needed insulin on a daily basis and couldn’t get it for that long? Seems like an oversite in the “switching insurance” procedures.
Enbrel is a rheumatoid arthritis medication that relieves swelling and stiffness in the joints. Unlike with insulin, you won’t die if you don’t take it. But it relieves a lot of unnecessary pain and suffering and can help restore a lot of movement if the RA is advanced.
My mother-in-law’s husband has very advanced RA and takes Enbrel.
It’s not an oversight. It’s a feature of a process that is designed first and foremost to prevent any payor from having to pay more than the absolute minimum amount possible and still be on this side of the law.
No one wants to front the money for medicine that might be someone else’s responsibility to pay for, and so processes are intentionally complicated, to the detriment of patient care.
It does a bit more than that, actually. It actually controls the disease, preventing damage to the joints. If your disease is severe/advanced, you don’t want to be skipping doses. Mine is moderate, but I have serious damage in my cervical vertebrae that my doctor is very concerned about. On x-rays my neck looks like an elongated knot of bone and you can only identify what looks like parts of normal vertebrae here and there. I really should NOT be skipping my Enbrel doses because of that. Over the counter Alleve only does so much.
I’m guessing they are waiting for a preauthorization. I’m on Humira and it requires one. I’m sorry you are dealing with this. My husband and I have been through a few insurance changes recently, long story, and, of course, every freaking time, it was a different company, different pharmacy.
Front office staff is so important in a doctor’s office. My husband and I have only stayed with our primary for years because the office we typically go to, the receptionist is a joy. I can’t stand dealing with the other office. I hope it all gets straightened out for you, and btw, the office staff and the insurance company should both know what’s needed or be in communication with each other and save you some time and stress.
Well for starters it’s not true that all insurance companies only Enbrel thru their specialty pharmacies; your old insurance company apparently let it be filed at your local pharmacy. :dubious: Also did you actually tell your doctor’s office to send the prescription to the new specialty pharmacy instead of the local pharmacy you’ve been using.
Sometimes I think the office staff in Drs offices are underpaid for their duties, other times I think they all should be fired. They act as if you were asking them personally to pay for your refill, when all you need is a note sent back to the nurse. I am insulin dependent T1 diabetic. I have to advocate and sometimes scream to get my needs met. I never take chances and boy they know it by now. I am pretty good friends with my Nurse practitioner in this office which goes miles in greasing my squeaky wheel.
Only my dentist has front staff/onsite office help.
The kids’ dentist … outsourced but since it is the same plan for the last 25 years and we gave up on my tribal secondary insurance paying for anything except now and then back in the day (totally gave up on them with the last child) we just pay what is owed.
My ob/gyn (really just gyn): took a while and several calls between Husband’s insurance and them. New insurance company for the company he works for. But for some reason they (the ob/gyn place I have been going to for over 25 years) couldn’t be bothered to pass on to their med check? places ie blood stuff or other cellular stuff testing that there was a new insurance.
Then going to a nose/allergy/dunno doctor and getting a sinus MRI? separated by 2 months but also split into a new year. That billing has been scary. Yes, I had 2 MRIs. 2 months apart. Apparently the first billing of the second MRI was deemed a double billing, doctor’s office said #2 never got paid, insurance said they got billed 3 times… and 7 months later both places are finally talking to each other.
I hope.
I mean, I am extremely lucky that my Tribal (not)insurance pays for deductibles and co-pays but I don’t want them to pay extra for screw-ups. It’s not like casino revenues have grown in the last 10 years (they haven’t) and all the other things the Tribe (err, Band) are putting our casino earnings into are paying back to us (strangely, no). So I will be appreciative for my health woes being paid for so I have no out of pocket costs. (I do miss the days when my non-member husband was paid for insurance wise as well).
The whole “needing to change everything medical because you changed jobs” is completely fucked up. Switzerland and France manage to have people changing medical insurance without needing to change doctors and pharmacies (UHC through private insurers, both of them). I know, I know, it’s the USA and everything has to be different.
I’m surprised that you couldn’t get Enbrel at little or no cost through the company, due to this interruption in your insurance, or did you ask? In the future, it doesn’t hurt to contact the drug company and ask about this.
Here in the UK we have UHC through the NHS , so I’m covered whatever job I’m doing (or if I’m unemployed.)
I have had private medical insurance as well at one company and that started the day after I joined.
Patients can’t afford their insulin as it is. Even with insurance “covering” it, a lot of them have to cut down their doses to try to stretch it out. Don’t even ger me started on the donut hole. Every year around September or October, the older diabetics go out of control since they can no longer afford their medication. Then in January there is the joy of the new insurances where we have to change everybody’s medications because the formularies have changed. My staff are great but sometimes we have to submit a prescription three or four times to get it filled.
Well, that one is easy. We just die and stop being a pain for the insurance companies.
But on a more serious note - I tend to hoard insulin, and I’m not the only diabetic I know who does that. My prescription is written to be slightly more than my needs are, and I get it filled the day the insurance lets me, so I always have months of insulin in the fridge. Call me paranoid, but given that I rely on it to, y’know, live, it gives me a bit of security.
At least around here, that’s the case. From talking to a local doctor friend of mine, he has a hell of a time keeping good staff for his office. He works for the local medical establishment, who sets the rates for office workers. He told me he’s had folks quit because they got a new job as a grocer store checker that pays better & has better benefits.
No, maybe your experience is different, but here is mine from the last 15 years. The process is that your doctor sends a new (or a renewal) rx to your local pharmacy. The insurance plan tells the pharmacy “no effing way” and then they trigger something so that their specialty pharmacy yanks the rx away from the local. When you get a new insurance plan, you get lots of info about what drugs they cover, but they never tell you what the name of their specialty pharmacy is, how to contact them or which drugs are required to go through them. So the above process is what you have to do, and then after the specialty pharmacy has your rx, then they contact your doctor’s office to get any required pre-auth and contact you to arrange shipping.
In the last 15 years of taking Enbrel, I’ve been through this around 8 or 9 times. Either I change jobs which results in an insurance change or my company changes insurance plans. I HATE employer-based insurance.
I sooo wish I could do that with my Enbrel. But since it’s around $1000/dose (how much the insurance pays), and has to be kept refrigerated, they are super stingy with it and I’ve never been able to refill it early enough to get even a 1-dose backup “hoard”. They only allow me to refill it when I have one dose left.
I also of course wish it wasn’t so freaking expensive. That’s the root of the problem, right there.
