APL just got an awesome new job (he is, in fact, skiing with his office today instead of working). But, of course, the new job came with new insurance. Luckily I was able to keep all of my doctors, but figuring out how to get my Enbrel ordered and paid for has been far less simple. It has taken eleven phone calls to get it all sorted out. And please keep in mind that all of these calls have to happen either during OZL's nap (which is also the only time I ever get to myself) or while simultaneously trying to entertain a 10 month old who has recently discovered that he has the ability to explore and get into everything.
CALL #1: APL calls Aetna insurance to ask how much we will be charged for my Enbrel and Cymbalta prescriptions. He asks about these prescriptions by name and in particular, because we know they are expensive and not always well covered. The representative tells him that with pre-authorization from my doctor, both will be covered at the regular co-pay of $30. We are happy.
CALL #2: I call my rheumatologist and give him the number needed for pre-authorization of my expensive meds. His awesome nurse faxes the info to Aetna right away.
CALL #3: Then I call Aetna insurance to ask them what pharmacy I need to use to get my Enbrel prescription filled. They give me the number for Aetna Specialty Pharmacy and tell me my doctor will need to call in the prescription.
CALL #4: I call my rheumatologist back and give him the pharmacy number. He sends the prescription over right away.
CALL #5: I wait a couple of days for the pre-authorization to go through. Then I call Aetna Specialty Pharmacy to set up delivery of my Enbrel. They tell me the pre-authorization hasn't gone through yet. I tell them I know my doctor has sent it already. They tell me to call back later.
CALL #6: I call my rheumatologist and talk to his nurse, who assures me that she sent in the pre-authorization info as soon as I asked her to. But she is extremely awesome so she calls them again right after talking to me.
CALL #7: I wait a few hours and then call Aetna Specialty Pharmacy back to set up delivery of my Enbrel. They tell me the pre-authorization still hasn't gone through, though I assure them that it has. They tell me to call back tomorrow. I figure I have no choice but to agree.
CALL #8: The next day, I call Aetna Specialty Pharmacy again to set up delivery of my Enbrel. They try to tell me that the pre-authorization still hasn't gone through. I tell them that is impossible. Then they change their mind and tell me that there is a problem with the date on the pre-authorization. I tell them that also is not possible because I know for a fact my nurse sent it in twice. After about 30 minutes of arguing and being on hold, they finally set up my delivery of Enbrel. The representative tells me that I will get a 3 month supply and it will arrive on Thursday.
To be fair, the Enbrel actually does arrive on Thursday. So points for that. But it is a one month supply instead of a 3 month supply. And we get charged $250.
CALL #9: I call Aetna Specialty Pharmacy again and say I have some questions about my shipment. This representative tells me that my insurance won't approve a 3 month supply, so I'll get an automated call to remind me to order my refill every month. Ok fine. Then I ask about the $250 charge. She tells me that because it is an injectable medication the regular $30 co-pay doesn't apply. Instead the policy states that we will pay 25% of the cost of the medication up to a maximum of $250. Since 25% of my Enbrel costs over $500, they charged us $250. So, apparently, the representative that APL talked to back in call #1 just flat out gave him the wrong information even though he asked her to check on our coverage for Enbrel specifically. But don't worry, the pharmacy representative tells me, there are some co-pay assistance programs out there. She gives me phone numbers for three such programs and I dutifully write them down.
CALL #10: I call the first co-pay assistance program. They tell me that I qualify for the program, but that it should have been set up through my specialty pharmacy. She instructs me to call the pharmacy back and ask to talk to a patient advocate.
CALL #11: I call Aetna Specialty Pharmacy yet again. I ask to speak to a patient advocate. The pharmacy representative has literally zero idea what I am talking about. I explain to her that I am trying to get some co-pay assistance since I can't afford $250/month for my Enbrel. She tells me I need to enroll through the co-pay assistance programs and tries to give me the phone numbers again. I tell her that I just spoke to the co-pay assistance program and that they said I needed to set it up through the pharmacy. She puts me on hold.
Without any warning, I am transferred to another department. I am surprised, but I re-explain what I am trying to do. This representative tells me that I already have co-pay assistance. I tell her, no, I was just charged $250 for my last shipment. She (rather rudely) tells me I already have it because she just put it in place for me. I (as politely as possibly) say that is great, and ask how much I will have to pay in the future with the co-pay assistance in place. She tells me it will be 100% covered.
You mean to tell me that the Aetna Specialty Pharmacy itself was capable of enrolling me in a program in which my co-pay would be zero dollars but it took me two weeks and eleven phone calls to get to this information?!?!?
Oh. My. God.
Mommy needs a drink. And it's only like 10am.
(Please enjoy the unrelated yet adorable picture of my son and his daddy. Looking at their happy faces is the only way I am managing to stay sane right now.)