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.)
Oh my gosh. This is absolutlely terrible sounding. I recently almost switched jobs until I realized that the new company's insurance doesn't cover "pre-exisiting conditions". I am so glad you got hooked up (finallY) with one of those co-pay assistance programs. My doctor gave me one of the co-pay cards that makes my co-pay 0 dollars instead of 400.
Being sick is way more than just physical symptoms!!!
I apparently was really lucky with ExpressScripts specialty pharmacy CuraScripts. They contacted me to set everything up, I get a phone call every month reminding me to set up delivery, and they were the ones that told me about the Enbrel Support program (granted it was after a few months of $50 co-pays, which I felt was reasonable). Sorry you went through so much crap!
Amazing isn't it? The frustrating incompetence is just stunning. So much of the cost of our healthcare I think is the result of this. Insurance companies are certainly not motivated to provide us with care, ;-p.
Just read your post while on hold...looking forward to call backs. On 25 minutes of hold as we speak.
Curascripts worked well for me. Then my insurance company switched and required that I use Accredo (another Express Scripts company). That was an absolute nightmare - the worst company I have ever had to deal with. All online reviews for that company are terrible. Now, my insurance company tells me they have dropped Accredo and are using Aetna. I just got through after holding for about 5 minutes (not bad). They tell me its been shipped and I should have it tomorrow. I'm not exactly holding my breath since this is what Accredo told me 5 straight times. Its been 3 months since I have had my medication due to Accredo. I really hope Aetna is better.
They are awful. I have made countless calls to them and they still have not shipped my daughters medicate. It took a month to get "authorization" despite the fact that the doctors office submitted the paperwork right away.
Have you tried the Enbrel Support Program through Amgen? Once you register for Enbrel Support you will only pay $10 for each monthly Rx.
DOUG: So sorry you have had such trouble with getting your daughter's medication. Man is that frustrating! And the Enbrel Support program is great - and I have certainly made use of them in the past. I recently discovered that there is also a separate Enbrel Support program that works with Kaiser insurance (as Kaiser otherwise won't take the regular Enbrel Support card). Best of luck to you and your daughter!
I, too, have had the same issues with my specialty RX with Aetna which is also a shot for my asthma. Each year I go through getting a new pre-certification for my medicine. I call two weeks prior to the date I am to receive my shot to get the appropriate paperwork faxed to my doctor's office and the doctor's office returns the paperwork via fax within 24 hours. For my 3rd year in a row, I am on hold 10 days later being passed around to try and find out why my approval is still not in the system so I can order the medication. I learned the hard way when the first pre-cert rolled around that I have to begin the process at least 2 weeks early and make follow-up calls every 2 - 3 days as the pre-cert will sit in the system until the squeaky wheel gets to squeaking. As far as payments go, my doctor was wonderful and gave me a number for copay assistance which was wonderful or like you, I would be paying hundreds out of pocket that I can't afford.
Bottom line, you have to be your own advocate and a squeaky wheel. One tip to offer, most, if not all calls are recorded. Keep a log of dates and times you call in and the information you receive on the call. If you find out at a later date that previous info you were given by customer service was incorrect, you can file a grievance with the insurance company and with your state's insurance licensing department. Just the threat of filing a grievance is usually enough to bring a supervisor into the conversation to rectify the situation.
Another Aetna customer....
I suffered with Aetna Specialty Pharmacy for years and finally got so fed up that I checked my Aetna coverage to see what my other options were. There were plenty of other specialty pharmacies on the list! Geez. I called CareMed and they made the switch for me, and life has been heavenly since then. Truly, it's night and day. I know your post was several years ago so maybe you are no longer with Aetna, but if you can switch, do it now!
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