Yes and no. They readily tell you if they use CVS/Caremark or ExpressScripts or Curascript. What they don’t tell you is what the names/contact info of the specialty pharmacies underneath those pharmacy management companies are. I’ve used all three in the past 15 years, but even with my familiarity with them, I can’t guess which location of the specialty pharmacy I should contact. They really seem to love to hide that information.
To summaries/graph it out:
insurance company -> pharmacy management -> specialty pharmacy -> specialty pharmacy location near you
sorry, I don’t mean to sound stupid with these questions, but I’ve never had anything but Tricare for health insurance (military and retired military).
I just find it strange and sad that you can’t call your insurance company and ask “What pharmacy do I need to use, Rite-Aid or CVS or what?”
For normal (read: not expensive or needing special care like refrigeration) drugs it’s that easy. But if they deem some drug can only be handled through their specialty pharmacies, then it’s exactly as hard as I’ve described. I’m sure that it’s another part of the “make it so hard to get it’s a disincentive to use and then we don’t have to pay for it” strategy.
I should add, to help illustrate, that I have other meds that are not expensive that use the method you describe. So I actually get all of my meds from two different pharmacies.
I recently had a insulin pen prescribed. You would think I wanted Dr.Whos sonic screwdriver the way they acted. I am back on needle injections because of the hassle. I, too, hoard insulin. I am too far out of town to risk running out. My Doc has over prescribed me a bit, so I am able to hoard. I can’t remember the last time I got close to it being a near emergency. The reason being i am on top of it. I don’t dare let down my gaurd.
The specialty pharmacy just called. They said that now that they have the prescription, they ran the claim with the insurance and discovered that it requires a pre-authorization.
Why do these people who work with this stuff every day always seem so surprised and caught unaware by the processes?
Also, and I’m just being peevish here I know, but… she said they were working on that pre-auth with my doctor’s office “so that there won’t be any delays”. I managed not to point out that it’s already been delayed by weeks. But with all the calls to them over this past week and my actually telling them in two of the calls that I’m overdue for my “next” dose, they never added that notation into my record so they wouldn’t say something so stupid?
I try not to take it out on the phone agents, though. Once when I was going through this and feeling particularly bitter, I looked them up on Glassdoor. That’s how I learned that the people who work for these specialty pharmacies are treated like crap and it’s a very high turnover job. Their customer service shows it.
I think the reason the insurance can’t say which pharmacy to use, is that they don’t know. My insurance company used emails, postal letters, and ads on their website to tell me to switch to their special mail order pharmacy. Fine, I filled out the form and clicked on stuff to switch, only to be sent a letter a few weeks later telling me that the special pharmacy they’ve been telling me to use isn’t covered by my plan.
Every state has different laws and regulations, and every (large, at least) company has a different contract with the insurance companies. I think it’s so complicated that they just can’t tell you how something works until they actually try and put a prescription through the system. When it gets rejected they try something else, repeat until it works or you go away.
And of course, as has been mentioned, every person who contacts them with a particular issue is the very first person that has ever contacted them with that issue, and the problem has to be researched and solved from scratch.
We dump carbs and go for the carnivore option … old school. We also up our exercise for those who are type 2 and still produce minute amounts of insulin. Burn that glucose!
Yup. I titer up and down from the prescribed dose depending on how screwy the cancer and treatment make my glucose metabolism. I also do Invokana and Metformin … I have at least 6 spare vials at both residences, and do the FIFO shuffle on the vials .
Sweet Jebus, I think you are the fist person I have heard of that does vial and syringe! I do it because I had the pens for a while, and had 3 successive pens screw up - one shattered, spilling insulin everywhere, the second locked and the unit wouldn’t turn, and the third wasn’t delivering the dose after the third or fourth injection. So I said screw it, when I draw a dose, I know I have drawn the damned dose and it goes where I shoot it.
[I can remember back in the old days of the early 80s mixing 2 types of insulin … the single vial that is also shelf safe for the 30 days after opening from taking out of the fridge is magnificent!]
Point 1: Insurance companies deliberately and continually employ strategies that are designed to save them money. This may involve switching which meds or supplies they provide coverage for, switching ‘tiers’ of coverage, requiring ridiculous prior authorizations (which are reviewed/approved/rejected by non-medical personnel), making it difficult to get in contact with them, and always being on the lookout for cheaper, less-effective alternatives.
Point 2: The front office staff at your physician’s office are very likely not incompetent (although they may or may not give a shit about helping you, that’s another matter). The much more likely scenario is that they are monumentally overworked and criminally understaffed and probably bogged down in an inefficient system. The sad truth is that they are probably just as baffled as you are by the ever-changing hoops that must be jumped through to get a freaking medication approved. And the hoops are going to change next month without good reason or warning.
Point 3: Nobody is dying because their insurance company is slow to approve their insulin. There are safeguards in place, alternatives to implement, and methods available to bridge gaps in coverage.
mmm
A necessity drug that costs too much for anyone whether they have insurance or not. It should be free for Type 1 people… us Type 2 people can do stuff like eat better (if we can afford to) or exercise (if we can). I’m glad I am not needing insulin … I’m mad so many who need it have to jump through hoops to get it. I thought by now just about everything would be free (Utopia).
France’s population is a puny 67 million. Do you have any idea how difficult it would be to scale their system up to the size of a real country like USA?
And what about America’s troublesome ethnic problems — the reason we can’t have good things? Only about half of French citizens have a foreign-born grandparent, but every American (except pure-bred Amerindians) has a foreign ancestor, many of them African, Mexican or Irish. [/sarcasm]
Actually, the larger the participating pool the better insurance works. France is a real country. We would implement this on the state level with each state has their own UHC, like the Canadian provinces do, if covering 300 million in one group is a problem either technically or politically.
Try again, your bias is showing.
What the frack does that have to do with health coverage?
(B) You needn’t spend much time listening to right-winger commentators to “know” that it is America’s “ethnic problem” that requires us to own guns and to avoid all social welfare programs.
You forgot how to deal with nasties like me, who had to find a dentist for a quick fix having broken a tooth in-country. No “out of network” stuff; I remembered too late where I’d put my insurance cards (in Spain I can just use my national ID or my driver’s license+, the cards live at the bottom of a connection between my backpack and the Marianas Trench) but the front office lady made sure I knew that I can claim my money back from the Spanish UHC system.
We really need to stop being so horribly Yuropian or something.
hands a big mug of Spanish-strength coffee to Broomstick*
using the license gets me nasty looks though. But they can’t complain, it’s only that a lot of paperwork-people like their things neat and the license has the info in slightly-different spots.
Insulin, maybe not. But there are other drugs that people depend on to continue living and I do wonder if they fall into this hole and either die or suffer physical injury from an out-of-control disease/condition. I don’t know if this has been studied. I just seem to remember hearing complaints by doctors about patients refusing or simply neglecting to take their medication and what harm they’re causing themselves by doing so. Strangely no mention of the same issue being brought about by insurance bureaucracy.
Edited to add: I actually did remember after posting this about one similar situation that is occasionally discussed: the Medicare Part D “donut hole”. It’s known that near the end of each year when many Medicare patients reach their “donut hole” and don’t have gap coverage, they start rationing their meds or go without. I am guessing that between this and situations similar to mine, a LOT of people frequently are forced to go off their meds.
Update: It’s now been 5 weeks for me. If I’m lucky I’ll get my Enbrel in a week or two, making it 6-7 weeks of not being able to take my prescribed medication.
I was curious about this statement, so I went over to Reddit and chatted a bit with front office staff of doctor’s offices in a health care subreddit. You’re right. They regaled me with horror stories of fighting with insurance companies over prescribed medications for their patients. One person said he’s seen a patient’s insurance plan approve without argument things like Viagra but fight tooth and nail over specific brands of insulin. Another person (an EMT) told a story about having to treat and transport a patient about to die of severe heart problems (saved his life) and then the insurance refusing to pay and practically telling them they should not have transported the patient to the hospital. Pretty abhorrent and it’s hard not to conclude that the insurance companies prioritize money over patient care.
A few years back, I needed to get an injectable joint fluid product (OrthoVisc, I think) that had to be filled through the specialty pharmacy - i.e. mail order.
It took several months to get it taken care of. The pharmacy people kept claiming that they couldn’t get through to the doctor’s office to coordinate shipment. They were flat out lying. Finally I had them conference me in when they tried to call - and yanno, they got through on the first try.
I spent a month trying to get my Metformin dosage tweaked from 500 to 1,000 mg. For some reason, it’s easy to get the 500 mg extended release pills, but the 1000 mg extended release pills required preapproval and were a LOT more expensive. Over a month of the doctor’s office and the pharmacy supposedly trying to contact each other - and nobody would just write me a scrip for two 500 mg pills a day which is the same damn thing. I nearly ran out… and I was going to be out of town, and my doc was out of town the week before I travelled and the office tried to say “we’ll take care of of it when doc gets back”. ARGH.
And today: I’ve got cataract surgery scheduled for fucking early Thursday. Lots of paperwork from the eye doc’s office saying “if we don’t have medical clearance by 11/30 we’ll cancel it!!”. I called them one day last week and left a message asking if they’d gotten the paperwork.
No response.
Yesterday, the office called me and asked if I could come in 45 minutes earlier for the procedure (well, they told me I had to… but I didn’t care). I asked if they’d gotten the paperwork. “Oh, S would have called you if it hadn’t gotten here”.
This morning I get a call reminding me of the out of pocket portion of the bill. AND they had not gotten the paperwork. So I called the internist’s office to get it sent - and they already had it all available (they even knew the fax number). But for whatever reason, they NEVER SENT IT.
So I have no clue whether the paperwork has been sent to the eye doc or not. And to add to the fun, I’ve got a large out of pocket to the eye doc for the lens, and to the surgery center for the laser portion of the surgery… and the surgery center is now telling me I owe them 500 bucks for the premium lens. WTF??? Why are two different organizations billing me for the same product?
To start, my Quacks office rearranged the deck chairs on the Titanic, and the aide for my Quack is MIA, or something. I had a sleep study, which after a 3 month kerfuffle, decided I have apnea and really need to be a hosehead. So be THAT. Then the fun started. After 4 weeks and nothing after getting the test results, I called the office, told my story to 4 minions, (Don’t you love the bullpen office?) and discovered after more phone calls that the useful idiots they farmed me off to are waiting for a signed script. Fast forward to today, when the Quacks office claimed that it was sent three weeks ago. I pointed out testily that as of last Thursday, they had no script, so send one again. I fear that I shall have to go medieval on a few peoples asses, as I know the Quack minions don’t give a shit, and the CPAP idiots Yelp rating is split between 25% great, and 75% one star screeds of anguish. It’s no wonder that I need blood pressure meds.
A necessity drug that costs too much for anyone whether they have insurance or not. It should be free for Type 1 people… us Type 2 people can do stuff like eat better (if we can afford to) or exercise (if we can). I’m glad I am not needing insulin … I’m mad so many who need it have to jump through hoops to get it. I thought by now just about everything would be free (Utopia).
France’s population is a puny 67 million. Do you have any idea how difficult it would be to scale their system up to the size of a real country like USA?