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Esteemed Contributor
Posts: 6,415
Registered: ‎03-09-2010

Diabetes: a financial/insurance question about injectable meds

An elderly family member and his wife are struggling with an issue and I thought someone here might be able to provide some tips.

 

They are on Medicare and have a Blue Cross supplement insurance.  Each individual prescription = 1 co-pay.  The wife is on 2 injectable meds:  toujeo and solastar.  Oral meds are not in the cards because her kidney values are too poor.

 

The endocrinologist writes a prescription for 30 or 31 days, but they can never get that number of pens without paying 2 co-pays a month, because the pens come in boxes of 19 and the boxes cannot be broken up (I don't understand why, by the way.  I've asked them who says they can't be broken up).  That means to get enough pens for a month, they need 2 prescriptions.

 

Yes, 8 pens rollover into the next month.  However, because of the 19 pens per box, they still are in the situation of paying 2 co-pays per month to get adequate numbers of pens in a given month -- which gets very expensive.

 

The husband is in an endless loop of phone calls with the Blue Cross people trying to find a solution; so far, no luck.  I told him I would ask the experienced people on this board to see if there is something he or the endocrinology practice is missing.

 

Thank you!

 

Honored Contributor
Posts: 12,031
Registered: ‎03-11-2010

Re: Diabetes: a financial/insurance question about injectable meds

They need to ask Medicare or a diabetes insurance that might answer their questions. How a primary care doc? Maybe Google this?

And there was no one left to speak out for me....
Esteemed Contributor
Posts: 6,415
Registered: ‎03-09-2010

Re: Diabetes: a financial/insurance question about injectable meds


@ncascade wrote:

They need to ask Medicare or a diabetes insurance that might answer their questions. How a primary care doc? Maybe Google this?


Ncascade, thanks for your response.  The husband is the wife's full-time caregiver (they have an aide to help out, not a health aide, however.)  She has numerous other health problems, so it's tough for him to stay on the phone to get the answers he needs from the insurer or Medicare.  Last week he spent two days on the phone with Blue Cross, 2 hours apiece on 2 different matters.  You know what a time-suck those calls can be, and they distract him from her medical needs. 

 

The primary care doc doesn't know the answer.  He's trying google, but he's not that computer savvy so I thought I'd ask here for him on the off chance that he's missing something simple.  Thank you!

Honored Contributor
Posts: 18,973
Registered: ‎10-25-2010

Re: Diabetes: a financial/insurance question about injectable meds

Have the doctor write an RX for 38 pens a month, instead of a 30-31 day supply.

 

that's the only way it will be one copay.

 

I worked in health insurance for over 20 years.  It's worth a try.

 

 

Honored Contributor
Posts: 9,416
Registered: ‎03-09-2010

Re: Diabetes: a financial/insurance question about injectable meds


@Carmie wrote:

Have the doctor write an RX for 38 pens a month, instead of a 30-31 day supply.

 

that's the only way it will be one copay.

 

I worked in health insurance for over 20 years.  It's worth a try.

 

 


Reading what I read about the insurance companies when it comes to prescription medications they probably wouldn't go for that.

Esteemed Contributor
Posts: 6,415
Registered: ‎03-09-2010

Re: Diabetes: a financial/insurance question about injectable meds

@CarmieI'll pass your suggestion along.  Thank you!

Esteemed Contributor
Posts: 6,415
Registered: ‎03-09-2010

Re: Diabetes: a financial/insurance question about injectable meds

@CelticCrafteryou may be right. He's truly between a rock and a hard place.

Honored Contributor
Posts: 9,416
Registered: ‎03-09-2010

Re: Diabetes: a financial/insurance question about injectable meds

@Sammycat1 - my niece was told the same thing about not being able to have the box of syringes broken up.  Hers come through a mail order so it's not like it's just a local pharmacist that made up the rule.

Honored Contributor
Posts: 12,940
Registered: ‎11-16-2014

Re: Diabetes: a financial/insurance question about injectable meds

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Honored Contributor
Posts: 18,973
Registered: ‎10-25-2010

Re: Diabetes: a financial/insurance question about injectable meds


@CelticCrafter wrote:

@Carmie wrote:

Have the doctor write an RX for 38 pens a month, instead of a 30-31 day supply.

 

that's the only way it will be one copay.

 

I worked in health insurance for over 20 years.  It's worth a try.

 

 


Reading what I read about the insurance companies when it comes to prescription medications they probably wouldn't go for that.


Don't believe everything you read.  Mostly everything today revolving around insurance is done by computer.  Claims are submitted electronically.

 

Because of this, Customer Service Reps are in the dark of why things are paid or rejected.  All they can do is look up your benefits and see if the claim processed correctly according to those benefits.  

 

I worked in insurance so long that I have seen what can go wrong or how they are paid when they are submitted.  

 

There re are many RX that are dispensed in a box with the capsules wrapped in foil.  There are mostly 30 in a box.  If you take 1 a day, one box is all that you will need.  If you take two a day, two boxes will be needed in a month also if you take 1 a day and two every other day two boxes will be needed.

 

 If the doctor writes the RX for 30 days and the standard Is 1 pill a day, the patient will get one box.  The RX should be written for two boxes a month for one copay.

 

the RX will go through the computer and no one will question it.  The insurance company is not out to get you or take advantage of you by charging you two copays.

 

there is so much government regulation involving health  insurance that no company wants to be fined or disciplined.

 

It's easy to blame problems on the use of computers, but it is unfortunally it is the case.  They are not human and can't use common sense.  You have to submit claims in the language they are programmed to understand.

 

there are some drugs that you need special permission to use more of than what is standard and they need to be preauthorized before that can be dispensed.  An appeal or a letter is required for those cases.

 

if the OP can't get a months worth of drugs to only charge one copay, she should write a letter of appeal to the insurance company.

 

It is possible, they can get a " fix" in place for this problem.