Rheumatoid Arthritis Support Group
Rheumatoid arthritis is a chronic, inflammatory, multisystem, autoimmune disorder. It is a disabling and painful condition which can lead to substantial loss of mobility due to pain and joint destruction. The disease is also systemic in that it often also affects many extra-articular tissues throughout the body including the skin, blood vessels, heart, lungs, and...
i'm seriously having trouble with this right now. i've been a fairly organized and responsible adult for the past few years (while i've been on my psychoactive medication). my mother was a customer service rep for a major health insurer for 26 years, most of my life. i know how to navigate the system.
until now.
the rheumy's office says they electronically sent the prescription. the specialty pharmacy has no idea what i'm talking about. the rheumy's office calls it in. the specialty pharma doesn't have it but requires it to be faxed in. the rheumy's office closes for FOUR DAMN DAYS because of a few inches of snow. this morning they said they'd fax it in. i call the specialty pharma and they said it could take up to 72 hours for someone to TAKE IT OFF THE FAX MACHINE.
flabbergasted. i'm calling you and telling you they said they faxed it - get up and walk to the damn fax machine and pick it up and PROCESS IT.
then the rep from the specialty pharma says i probably need prior authorization so it won't matter anyway. but she can't see that part of my benefits so i have to check with someone else.
i'm supposed to take enbrel again the day after tomorrow. i've been fighting this back and forth crap since 12/27.
i called the member services number on my card for pharmacy services and they TRANSFERRED ME TO THE SPECIALTY PHARMA WHO CAN'T HELP ME.
at this point i was ready to gouge my own eyes out. i called the regular member services number. i give her the very short version - i've been going back and forth with the dr and the specialty pharma and i want to see if enbrel requires prior auth. she says i see the rx here, your dr sent it to the wrong place. she put me on hold for a bit and just came back on letting me know that she's going to get the regular pharma and specialty pharma on the call together and have them transfer the rx from the regular place to the specialty pharmacy. but they can't conference more than three lines so i have to drop off and she'll call me back.
um, what? so my rx has been sitting there doing nothing and no one noticed. a script was sent to the regular mail order pharmacy - a script they couldn't handle - and no one thought to call and follow up on it.
i really hope this giovanna calls me back. otherwise i'm going to lose my damn mind. as it is, i'll probably have to skip this week's enbrel dose - which freaks me out because what if that messes everything up? seriously. so my script for enbrel syringes has been sitting there since 12/18/13 and just sat there. no one did anything. even with the five calls to aetna that i've made, no one thought to check with the 'regular' pharma team. i told them every time my doctor electronically transmitted it in front of me on 12/18/13.
anyway. i think i deserve a nap now. of course, the phone will ring as soon as i drop off, i'm sure. damn it.
until now.
the rheumy's office says they electronically sent the prescription. the specialty pharmacy has no idea what i'm talking about. the rheumy's office calls it in. the specialty pharma doesn't have it but requires it to be faxed in. the rheumy's office closes for FOUR DAMN DAYS because of a few inches of snow. this morning they said they'd fax it in. i call the specialty pharma and they said it could take up to 72 hours for someone to TAKE IT OFF THE FAX MACHINE.
flabbergasted. i'm calling you and telling you they said they faxed it - get up and walk to the damn fax machine and pick it up and PROCESS IT.
then the rep from the specialty pharma says i probably need prior authorization so it won't matter anyway. but she can't see that part of my benefits so i have to check with someone else.
i'm supposed to take enbrel again the day after tomorrow. i've been fighting this back and forth crap since 12/27.
i called the member services number on my card for pharmacy services and they TRANSFERRED ME TO THE SPECIALTY PHARMA WHO CAN'T HELP ME.
at this point i was ready to gouge my own eyes out. i called the regular member services number. i give her the very short version - i've been going back and forth with the dr and the specialty pharma and i want to see if enbrel requires prior auth. she says i see the rx here, your dr sent it to the wrong place. she put me on hold for a bit and just came back on letting me know that she's going to get the regular pharma and specialty pharma on the call together and have them transfer the rx from the regular place to the specialty pharmacy. but they can't conference more than three lines so i have to drop off and she'll call me back.
um, what? so my rx has been sitting there doing nothing and no one noticed. a script was sent to the regular mail order pharmacy - a script they couldn't handle - and no one thought to call and follow up on it.
i really hope this giovanna calls me back. otherwise i'm going to lose my damn mind. as it is, i'll probably have to skip this week's enbrel dose - which freaks me out because what if that messes everything up? seriously. so my script for enbrel syringes has been sitting there since 12/18/13 and just sat there. no one did anything. even with the five calls to aetna that i've made, no one thought to check with the 'regular' pharma team. i told them every time my doctor electronically transmitted it in front of me on 12/18/13.
anyway. i think i deserve a nap now. of course, the phone will ring as soon as i drop off, i'm sure. damn it.
I have new insurance as of Nov 1. I was on Humira before that with no insurance getting it free through the Abvie Foundation. Trying to do the right thing, at my last Rheumatologist appointment in November I brought along the formulary list which had Humira on it, and asked the doc to start the pre-authorization process as I don't want to take advantage of the free medicine now that I have insurance.
I got a denial letter 10 days later stating that Humira was not on the formulary, but Enbrel was. Assuming the doc's office would take care of this and send in the pre-authorization for Enbrel I waited a week. Now it is the second week of December and I have one shot of Humira left.
After 3 phone calls on separate days to my Rheumatologist office, each time I was told that someone would get back to me. Nothing.......So I decided to write a letter directly to my doc with the expatiation including the letter about using Enbrel. In that letter I kindly asked for an explanation if he wasn't going to process the rx for Enbrel to at least communicate the reason to me. No response from that either after 2 weeks.
So I took my last Humira shot on Dec 19th and here I sit. I called my insurance company and the specialty pharmacy and neither has any record of any rx for Enbrel.
I'm done calling and begging. My next appointment with the Rheumatoligist is the 3rd week of February - by then I will be back hobbling in with my cane.
I hope the nap was successful in making the day more tolerable
Be well, stay warm and SMILE - it makes them wonder what you know they don't
Peace
Bluedogs2
i took it upon myself to call aetna speciality pharma *again* and this time the rx was there! i verified all the info for shipping and asked about a sharps container because it said on the website it could be supplied. i didn't get the answer i wanted, but the guy seemed a bit frazzled anyway. he asked me the name of the medication three times.
at least he got it all right.
when they call tomorrow to verify the billing info or whatever, i'll ask about that. the website says they can supply free alcohol swabs and sharps containers. i'm using an old protein powder container for now, but one of those fancy ass red BIOHAZARD things would be fun too.
My experience with specialty pharmacies is that it takes 10 days to two weeks to get approval for biologics. With the holidays being in the mix, double that. My experience also is that the right hand doesn't even know the left hand exists, much less what it is doing. If the "customer care" people call, hang up immediately or they'll screw it all up beyond belief.
My doctor HAD to send my script to my regular pharmacy first and have them say they weren't allowed by the insurance to fill it before she could send it to the specialty. I guess it's some kind of Renaissaince court dance with all the bowing and kissing of hands and curtsey-ing. If you are in a bind meantime, your doctor's office should have an emergency stash.
Have some follow up questions after reading the "experiences" we'll call them here on the board.
I have great ins BUT have to use mail order for any long term meds past 3 refills at the pharmacy. Here are my concerns since I'm soon to be starting Enbrel/Humira:
1)Do they carry these at the pharmacies-Rite Aid, etc? I always have to follow up as it is because the autorefill from the pharmacy isn't compatible with the Dr's computer system or whatevertheheck.
2) I do have to use mailorder pharmacy for ongoing Rx's pas 3 refills, etc. Are these specialty pharmas you're referencing related to the mailorder-ExpressScripts etc.?
3) Is your share of cost larger than the normal prescription for generic or brand?
I'm sick to my stomach now thinking about all this and that it may not work. I'm glad its a topic tho so others like me can learn about it.
I work in HealthCare so I'm familiar with the telephonehell you poor souls have had to deal with-I'm truly sorry for anyone who has to endure it.
Of course being a small country down here our salacious media loves little "human interest" stories involving the Bad Guy and Innocent Victim. However, wouldnt occur here over a prescription as the way pharmacies, medicines and drugs work is different.
Just another vent...sorry...this has not been a good last few weeks. Pain will do that to you..
i have already filled out the application for the enbrel support card - they state that the first 6 months of enbrel will be at no cost and the next 6 months will be no more than $10. this is NOT available to anyone on state/federal government funded insurance (medicaid, medicare).
as far as the insurance companies dictating what we can and cannot take instead of doctors - don't get me started on that. i already had one huge fight with aetna about my psychoactive medications. i took that fight to twitter and got it resolved fairly quickly.
what it is is a 'panel' of 'medical personnel' look at different medications and determine what is reasonable and customary. let's say that skittles are the best medication for RA, but m&ms and razzles work in a similar way and are less expensive. the insurance company wants to spend as little money as possible on each customer.. er, patient. so the insurance company will not cover skittles until you try either m&ms or razzles and they don't work.
cassie2u, your insurance company may require you to have tried mtx for three months with no improvement, or may require you to try enbrel and fail before covering humira. you should be able to get all that info from your insurance company and/or pharmacy carrier. and once you determine what you'll be taking, apply for cost assistance on the website.