Wellness

[KLm]

I agree with the advice to get the doctor to write the script a different way.

Explain the situation to the doc or the doc's nurse and tell them you need a script for 38 pens. 

In my experience, doctors and nurses aren't familiar with all the ins and outs of these packing and/or dispensing issues. Nor should they be.  But whenever I've explained my situation they have helped me out. Good luck.

[Nightowlz]

---

@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.

---

@Carmie ITA. There is a way the doctor can write the script so it can be filled for a month.

My Ins quit paying for my thyroid med because it's not FDA approved. Before they stopped paying for it my script was wrote to take 1 1/2 pills per day and 1/2 pill 3 times weekly since that's the amount I have to take each month to keep my thyroid levels where they need to be.

I'm not on Medicare + supplement yet but seems like they should be able to write it so you get what you need for the month.

[Trinity11]

-

[tansy]

I had to look up Solostar as I hadn't heard of that name.  It turns out to be Lantus insulin which I use nightly.  I get mine in vials, which is probably less expensive. 

ETA:  Have them talk to an insurance broker to find the best supplement or Advantage plan for their meds.  The plan the agent steered me towards saved 2k on my RX expenses.

[chrystaltree]

---

@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.

---

       It's still worth asking.  Nothing ventured, nothing gained.  Insurance companies to make exceptions from time to time.

[Sammycat1]

To all contributing their thoughts and opinions:  thank you.

Yes, vials and traditional syringes would be less expensive (not by much, it turns out, on their insurance).  But the wife has severe rheumatoid arthritis in both hands and can't self-inject; the husband has severe trigger finger and only can handle the pens at this point.  Realistically, soon they will need a medical aide, which is available to them.

Yes, the wife's diabetes is tough to control.  As I said, there are other serious medical issues -- and some recent surgical ones -- that contribute to this.  It's obviously a complex medical management situation.  There's nothing else "to this" than that. 

I'm passing all your thoughts along -- again, thank you.

[chrystaltree]

---

@Carmie wrote:

---

@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.

---

       Actually, the doctor should appeal based on clinical criteria.  It's called a peer to peer discussion.  The patient's physcian discusses the situation with an insurance company doctor.  The insurance company doctor or medical director can over ride things like this but it must be for medical reasons, not financial ones.

[noodleann]

I can only share my darned if you do, darned if you don't story.

After cataract surgery I had to be on a special eyedrop Rx. It was only sold in XmL bottles, can't remember the amount. I had to discard it after the first eye, and knowing I'd be on it for a while, asked that the Rx be written for two months.

The same bottle, with the same amount, was dispensed, but I was charged two co-pays. Why? Because the Rx spanned two months. Same amount of product, but they double-dipped on my share. Thank you not, Medicare Advantage. But lesson learned.

I really don't think there's any way to game the insurance racket to make it fairer. They've got all the angles covered.

Don't make any assumptions about what ought to be, based on logic. It may not apply. The only things that matter are the insurance company's rules and whatever allowances they make for special cases. It's such a shame that the assistance programs for this drug are not available to people on Medicare.

[Moonchilde]

---

@KLm wrote:

I agree with the advice to get the doctor to write the script a different way.

Explain the situation to the doc or the doc's nurse and tell them you need a script for 38 pens. 

In my experience, doctors and nurses aren't familiar with all the ins and outs of these packing and/or dispensing issues. Nor should they be.  But whenever I've explained my situation they have helped me out. Good luck.

---

This^^^

I am on oral Metformin. I wanted to switch to extended release. It's well known that insurance companies won't pay for ER versions of this drug. My doctor knew and said expect to be turned down; I was. Some months later, we tried again. He wrote the Rx for a slightly lower dose, and it came as a 90-day supply (which I wasn't expecting) rather than 30. My co-pay was $4 (the first time we tried my cost was $400+ or a 30-day supply).

I don't know if he found out the specific way it needs to be ordered - mg dose, or 90-day supply, or ?) or he was just taking a stab, but it worked. All of my other meds are 30-day suppies, so the 90 days sounds like it might be the tipper. I'm sure that insurance companies don't want doctors to know the best ways to get something paid for - I'd be curious to know how a Caremark rep, for example, would respond if directly asked by a physician.

[Carmie]

---

@chrystaltree wrote:

---

@Carmie wrote:

---

@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.

---

       Actually, the doctor should appeal based on clinical criteria.  It's called a peer to peer discussion.  The patient's physcian discusses the situation with an insurance company doctor.  The insurance company doctor or medical director can over ride things like this but it must be for medical reasons, not financial ones.

---

Those types of appeals are reviewed if the claim or service has been denied. Example: for a medical necessity issue. The provider should not appeal for a copayment issue.  

The medical staff at the insurance company does not get involved with copayment, deductible or payment issues.  They review for medical necessity.  Sometimes, they approve the service as medically necessary, but if the service is excluded on your policy, it won't be paid.  They can't over ride your benefits.

there are other employees who can work to get a benefit over ride.  They usually have to get permission from your employer if you have coverage through them. Paying for a service that is excluded is going against a legal contract that is in place.  I have had some employers who would not give permission to cover an excluded service for their employee even though it was medically necessary. It happens.