
Why does every January always feel like one long, drawn out Monday?!? I would love to blame it on the frosty weather or the fact that it feels like it’s gloomy and overcast EVERY day, but the reality is that I have dreaded January since I became a CF wife. Why is that?!? Insurance. Plain and simple. Let me tell you a tale of January, high blood pressure and insurance companies’ incompetence.
Years ago, I learned that January was not my favorite month. Usually, the culprit was Pulmozyme. That one always seemed to be the one that needed to most problematic prior authorization. Once I FINALLY got the hang of reaching out to the provider early, things got a little better.
Then, I changed jobs. How dare I, right?!? So, the conversations with ALL the providers, the insurance company and my personal favorite, Medicare. I mean, who doesn’t love a 45-minute hold time prior to an hour-long conversation to coordinate who is actually primary payer when I already knew the answer!? But I digress.
This year was no different. I knew that the hubby was going to need Trikafta filled, so I waited until after January 1st to call and guess what?!? There was a problem!! Insert a shocked face here. I work for a healthcare system and our insurance requires us to use our employee pharmacy for most things, but obviously, Trikafta can’t be filled there. So, our “preferred” specialty pharmacy is Optum, but since the hubs take Cayston also, we got a waiver to use Accredo for both. When I called Accredo, I was told that they couldn’t fill it as they were not in network.
So, call number one to insurance. During this call, I was told that Trikafta was no longer covered by our plan. I immediately started panicking because he had like five days’ worth of meds at this point. Because I have him on speed dial, I reached out to our plan’s administration to see what was going on as we had received nothing to say that there had been a coverage change. Another hour of back and forth to get to the bottom of the problem.
I called Optum, because they were the preferred pharmacy, to set up the order only to be told that the Trikafta would be $8.534.72. I almost threw up. Clearly, I knew that was incorrect, but still, hearing that amount made me pause for a minute. I politely told the person on the phone that the amount quoted was incorrect, explained that our FAMILY out of picket max was only $4000 and that the med should only be $100. She told me I was mistaken and that this was what it was.
I reached out to Accredo, because again, I was assured I could fill it there as well and I knew that the prescription had been there first only to be told that their pharmacist had cancelled the prescription since they were not in network. Cancelled as in I know had to call the doctor to get a new prescription. I had no words at this point…. well, I did…. most of them were of the four-letter kind. So, I sent an SOS to the Pharmacist at his clinic, and she thankfully got a new prescription sent over and we were able to get it filled for the low cost of $100…. which is what I had said to begin with. **palm to forehead**
Come to find out, the issue is that every November, I have to reach out to our plan administrator to get them to give permission for us to use Accredo or Optum for these meds. Basically, a button is clicked, and they are magically in network. The frustration that I have is that it should NEVER be the patient’s responsibility to do ALL of this. Only because I have been dealing with his meds forever do I know how all of this works and know which questions to ask and of who to ask them…. but OMG…the nightmare!!
But it made me wonder, when faced with these obstacles like this, how many people just say, “Screw it…” and do without? Or how many people have no clue where to start when they come up against something like this?
I would love to hear your horrific January insurance tales or if you have a positive story, I would love to have some hope for things to not be so crazy!!!
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