For Everything There is a Season

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Category: Medicare

Prescription Drug Coverage Tips

July 11, 2017 / / 4 Comments

I’d like to share a little story with you. It serves two purposes. The first being I get to sound off about this issue because well, isn’t that why people blog? OK, just kidding. The real reason I am taking the time to write this is because I have some important information to share that I think some of you may find useful.

After being diagnosed with a blood clot in my leg in 2004, I was tested for several different clotting disorders and found out I had a genetic blood clotting disorder called Factor V Leiden. Then in 2012,, I was also found to have two small blood clots in my lungs. Technically someone like me is supposed to be on blood thinners forever. Why I don’t take blood thinners regularly is a long story for another day. Actually, I think I may have told the story already. I’ve been blogging for a while and I lose track of my topics.

My medical plan is that under certain circumstances, I have to take a blood thinner injection called Lovenox. For example, I flew to Ireland last summer and had to take an injection before each of my six hour flights. No biggie.

About two weeks ago, I had surgery on my ankle. It was a big deal kind of surgery in that I cannot bear any weight on my left leg for 6-8 weeks. That is a blog story to be told all in itself which I will get to soon, I promise.

Because of the non-weight bearing status, I was prescribed Lovenox injections every day for the entire 6-8 week period. My risk of developing a blood clot after surgery was (is) substantial. The injections for me are no big deal. I’m a nurse, I’ve done them before, and it is just a part of the plan for me anytime I need orthopedic surgery.

The day of my surgery was long and tiring. Not to mention stressful. The hospital is two hours away. We had to be there at 6am and I think we got home around 1:30pm. My husband dropped off my prescriptions at the pharmacy. About two hours after I got home, the pharmacy (CVS) called to talk to me about the Lovenox. They wanted to check with me about filling it because the insurance doesn’t cover it and it was going to cost me $550 for a six week supply.

$550.
Let that sink in for a minute.

That can’t be I told them. It must be covered. I have to have this medication. There was nothing they could do I was told.

So I’m still messed up from the general anesthesia and I call my prescription plan, Aetna. I have the Aetna through Medicare Part D. They tell me that the issue isn’t about it being covered. Aetna does cover Lovenox. The problem was that it was a Tier 5 drug AND I was in the donut hole for Medicare.

For those of you who don’t know what that means, the donut hole is the point in your Medicare prescription plan where you have to start paying a much larger portion of your own medications until the total cost of your medications reaches a certain amount. It’s much more complicated than that, but that’s the gist of it. I’m very careful about avoiding the donut hole and this is the first time I’ve gotten there, likely because of a VERY expensive, new eye drop for Sjögren’s that I tried this year. The eye drops were a bust and now it was a bust for my prescription benefits as well.

I told the Aetna representative that this was ridiculous. If I didn’t have this medication, I could die.

I COULD (LIKELY WOULD) DIE.

I asked her if there was anything I could do.
Pay attention here.
This is important.

She said I could have my doctor’s office call Aetna and request a tier exemption. If it was approved, I would be refunded the difference by the pharmacy,

I’ve been a chronically ill patient for quite a few years and I had heard of this. I know that if you need a medication not on the plan’s formulary, your provider can apply for an exemption and get it approved, but I did not know about this tier exemption business. Very good to know.

I got off the phone and called my doctor’s office requesting that my provider call Aetna and request the tier exemption.

Meanwhile, the pharmacist from CVS called me and told me that if the doctor changed the prescription, I could save $200. What?!? This is my second important point in this blog…

Apparently the doctor ordered a 0.6ml syringe but I needed to only give myself 0.4 ml. This means that I would just adjust the syringe before I gave the injection and waste 0.2ml. The pharmacist told me that they medication comes as a 0.4ml syringe and that is why I would save so much money. He told me he had already called my doctor’s office and requested the prescription change and would hopefully have it for me that evening. So my husband and I decided that we would pay the $350 and just pick up the syringes so I could start the medication.

It is SO important to have a relationship with your pharmacist. Mine has known me for years and I truly think he has my best interests at heart. I never would have known about the syringe dosing. It’s obvious from this experience the importance of advocating for yourself in regards to medication prices. Ask your pharmacist if there is an alternative available. In my case here I got the same medication and the same dosage just by somebody paying attention and knowing the medications.

I got my medication. My doctor called Aetna as requested and the tier exemption was approved. I was psyched! I got a letter from Aetna confirming the tier exemption. It didn’t say what the new tier was but I dropped it off at the pharmacy. i called the next day and asked them to run it through for the refund.

It wouldn’t go through.

The pharmacist called Aetna again and he was told that I wouldn’t get a refund because I was still in the donut hole. He then explained to me that right now, it doesn’t matter what the tier or my resulting co-pay is because I am paying the donut hole price for my medication now anyways.

Duh, of course.

Between the lingering effects of the anesthesia and the heavy doses of pain medications, it slipped by me that this was the case: there was no way I could get money back right now. Ten days of going back and forth with Aetna, my pharmacy, and my doctor’s office for nothing. And I only went through all that for the tier exemption because somebody at Aetna told me that was what I needed to do to pay a lot less for the Lovenox.

I did call Aetna and spoke with a supervisor and explained what had happened and that I was upset that while I was recovering from surgery, I had to deal with all this (for ten days and with at least seven phone calls) because their reps are not well informed or knowledgeable about how prescription benefits work. I was told the issue would be addressed. And then, I let it go.

I am going to spend some of my recuperation time this summer comparing Medicare Part D prescription plans so when open enrollment comes in October, I can make a switch if I can find a better plan to suit my needs. In 2017, some of my prescription co-pays have skyrocketed, several of them have a copay price 3x higher than 2016. Maybe this is across the board and I will find there is no better alternative for me, but I have to at least investigate the possibilities.

This whole situation scared me though. I am on disability. I work very sporadically and when I do, it’s not a lot of hours. I am fortunate in that I have a husband who works full-time and makes a good living. I also have a family that I know would never have let me go without this medication. But there was a time that I was single, on disability and not able to work at all. I could not have afforded this medication without help from my family.

So what happens to all the Americans out there who need life saving medications like this and don’t have a husband with a job or a family to go to in crisis? I know people in this situation. And I will tell you, they don’t need that burden on top of already having a severe, chronic illness. Just some food for thought.

I hope this was helpful.
Remember, be informed and ask questions!

Medicare, Blue Cross/Blue Shield, and Me

September 21, 2012 / / 5 Comments



Found this kind of funny since I have a busted up foot and have no health insurance. Well, at least at the beginning of the story…

 

Note: This essay was written Thursday September 20,2012

My best friend, who also is disabled and struggles with her own chronic health issues, recently made a statement to me in reference to how I was feeling about unexpectedly not having health insurance. She said that for people like us, having your health insurance abruptly ripped away from you is like a person suddenly being laid off from their job. Those of us who are disabled or have chronic illnesses may depend on our health insurance every single day just like most people have to depend on having an income from a job every single day. Once that gets taken away from you unexpectedly, how do you feel?

Anxious.

Angry.

Fearful.

There is a long story to why I have lost my health insurance twice since July 2012 and when I have more energy and more answers, I will blog more about my experiences with the Social Security, Medicare and disability systems. Today, I just cannot because the system has me completely exhausted and worn done and I want this entry to focus on the miraculous thing that happened today. A thing that despite all the negative things we have to say about the health care system, the insurance companies, and the government, proves that there are good people out there who care.

The short version is this. I switched from my ex-husband’s health insurance that I was on as part of our divorce agreement to Medicare Part B July 2012 as I found out I was being dropped from his coverage. I had been eligible for Part B for quite a while but chose to stay on his as it had better coverage and was more affordable. I had notified all parties involved about my decision and took all the appropriate steps and was told that if and when I was dropped from my ex’s group coverage, I would be eligible for Medicare Part B through special enrollment which is what I did. Because of my extensive medical care needs and Sjogren’s specialists that are only located in CT (I live in MA), I also signed up for a Blue Cross Blue Shield (BCBS) PPO Medicare plan; known as a Medicare Advantage plan. This became my official insurance for everything. It cost a lot more for premiums, co pays, drugs, labs, etc. but was my best option at the time.

Social Security Adminstration (SSA) made a huge error and dropped my Part B in mid July which in turn dropped me from BCBS. To this day, nobody can explain the error. It was a fiasco. They still owe me large sums of money that they mistakenly took from my monthly SSDI checks. Errors they have admitted to but have yet to set straight. However the health insurance was put back in place after approximately two weeks and life went on.

I contacted Congressman’s John Olver’s office in western Massachusetts to assist me in getting this money back. They began to diligently work on the issue but meanwhile once again, without notice, my Medicare Part B was dropped in September without an adequate explanation except to be told there was a systems error. This of course prompted BCBS to drop me from their plan which is standard procedure, leaving me with no medical coverage at all. I had no notification except from my local CVS pharmacist who called to notify me that one of my refills did not go through because my insurance was denied and then a voice mail from SSA saying “you no longer have Part B, I don’t know why, and don’t know what to do about it.” I was unable to connect with my case worker at SSA however I was able to speak with the congressional aid at Congressman’s Olver’s office who started to follow through on the issue for me.

Meanwhile I was dealing with an exacerbation of my Sjogren’s syndrome which required an increase in medications and more lab work, an orthopedic appointment of a six month old sprained ankle that had gone bad, and an MRI. I started physical therapy for said ankle and then had to stop as I had no insurance and was worried the issue won’t get straightened out as by this point I didn’t understand what the issue was or what was going to happen next.

I have learned to handle stress very well. I have to with an autoimmune illness because stress just makes my symptoms worse. But not having health insurance puts me in sheer panic mode and I had my first panic attack in years. I became afraid to answer the phone or check the mailbox because it was always bad news that just made my situation worse and more frustrating. My days became filled with dealing with emails, phone calls, documenting every single thing said or done, working with health care providers and the pharmacy; the list goes on and on.

After several straight days of dealing with this, yesterday I heard back from the Congressman’s office who told me she got me reinstated in Medicare Part B but being the skeptic I am, I knew I would not feel sure about this until I called BCBS the next day to get reinstated with them because they would check the system and I would know for sure I was all set.

So today I called and sure enough, according to the system, I did not have Part B and could not get my BCBS back. I told the rep how I had to borrow money to pay for my medications yesterday and had to cancel appointments which was concerning since I just found out that my MRI showed a torn tendon in my right ankle. Also I had missed an important eye doctor appointment today. She promised me that she would flag my file and watch the system for my name to come through as maybe I went into the system late yesterday at SSA and might come through tomorrow morning. I knew better though. It wasn’t going to be that simple.

So I hung up and just cried. I asked God why can’t the people in charge just make this right so I can get the care I need and so I can not feel so riddled with anxiety to the point where I feel like I am on the verge of panic? Don’t they realize because of my health issues how vulnerable I am? I have utilized every resource I have. I prayed for the strength to just keep going.

And then the phone rang. I hesitated to pick it up because well, it’s always bad news lately. It was a woman named Judy from BCB. She told me that effective today I will be fully reinstated onto my BCBS plan. I told her that I had just spoken to someone from BCBS who said I wasn’t in the Medicare Part B system yet so that couldn’t be done. This woman said that yes, that is true what the previous woman said and that that same woman had then contacted her and that the priority to them is that I receive the medical care I need. And apparently she was the one that was going to make that happen.

I started to cry, a lot.
Because I had health insurance again.
Because I could get the care that I needed.
Because someone cared enough to go to the edge for me.
I was no longer just a number.
I was a human being.

She said my coverage will be retroactive to July 1st (as it should be) and she will check to make sure that none of my recent claims will be denied. She said she needs twenty-four hours to get my prescription coverage in place but to bring all my scripts, including ones I paid for out of pocket so far, to CVS and they will be covered effective tomorrow. She said to make sure I attend my physical therapy appointment tomorrow and to be assured that I now have medical insurance. She will deal with the rest. She was my angel.

This is what happens when God is listening and when you are fortunate enough to find your way to the compassionate people who work in the health insurance industry. Thank you Judy.

Addendum: I called Blue Cross/Blue Shield again today September 21st to reconfirm that I still have an active policy because well, it just seemed all a little too good to be true. And yes, I still have coverage. So today I am off to get a prescription and another much needed physical therapy session. God is good.

























































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