A Tale of Two Prescriptions

At the pharmacy today:

Me: Hi, I have two prescriptions ready, but I’m only picking one of them up.
Pharmacy Lady: Sure, can I get your name and birthdate?
Me: [name, birthdate]
PL: (looking at computer) And now, which one … wha … wha … WHOA, WHAT!
Me: Yeah, that’s why I’m not picking that one up yet.
PL: WOW.

So for my Crohn’s disease, I’m currently taking two medications. One (Azasan) is a daily tablet, the other (Cimzia) is a monthly injection. I’d been getting the monthly injections via the pharmacy’s mail-order system, but it’s a real pain in the butt, because the medication needs to be refrigerated. So they sent it overnight, and I had to sit at home until the FedEx guy brought by a styrofoam cooler so I could sign for it.

We just changed prescription drug plans at work, so I figured I’d take the opportunity to start filling that prescription at my local pharmacy. That way, instead of killing half of my Saturday waiting for the delivery, I could just stop by the pharmacy (which is in the parking lot at work) on my way home and grab the box of stuff.

Well, this new drug plan doesn’t like the Cimzia. They say it’s not a “preferred” medication, so they won’t pay a single cent for it. If I want to just pay a co-pay, I can have my doctor switch me to Humira or Remicade or Enbrel. But if I want the Cimzia, I have to pay the full price myself. Which for one monthly dose comes to … $1500.

Wha wha whoa what, indeed. Good thing I already have an appointment to see my gastroenterologist in a couple of weeks. Either he and I can collaborate on the long, drawn-out appeal process to try and make the Cimzia a “preferred” drug, or he can switch me over to Humira. We’ll see what happens.

On the plus side, the Azasan tablets were $110 for a 90-day supply under the old plan. With the new plan, I just paid $43. That probably would have delighted me if I’d heard about it before the whole $1500 thing.

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3 Comments

  1. A lot of drug plans have a loophole called “Prior Authorization.” If you can get your doctor to fill out a form that basically says, “No really, this drug is necessary, and there aren’t any cheaper substitutes that would work as well,” they’ll cover it.

    I’m not sure if you knew about that or not, but I figured I’d throw it out there. It seems like the sort of thing some insurance companies wouldn’t tell you is an option unless you ask.

    Also, you could try talking to your Human Resources department. If they call up the insurance company and insist you need it, the insurance company might actually listen.

    (I went through a similar nightmare a year ago trying to get cluster headache medication, so I learned about this stuff then.)

    [Reply]

    missy Reply:

    I have prior authorization on file already. That’s what initially confused the rep I talked to — she couldn’t figure out why they weren’t covering it. But even with that in place, it’s still listed as “non-preferred” and won’t go through.

    I don’t even know who I’d talk to in Human Resources, with a company this huge. But I’ll keep that in mind, if going through my doctor doesn’t work.

    They’re also mailing me (how quaint!) an appeal form, so I can do some groveling of my own to get them to make the stuff “preferred”. Really, it sounds like they’re in bed with the companies that make their “preferred” drugs, which would be kind of sickening.

    [Reply]

  2. Yeah, I sympathize. I take 9 meds a day (14 pills) and have to get an IV once a month for my RA.

    [Reply]

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