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    #1

    Insurance/Specialty Pharm

    I'm not sure if I should post my question here or in the Avonex forum.

    Anyway, long story short, I am dealing with what I can only say is the worst specialty pharmacy group in the 10 years since I was diagnosed. Not sure if I'm allowed to give the name, so I'll refrain. I called to refill my script two weeks ago, the rep refilled and said I would receive my refill on 10/14/2016. One week and a day before my shipment was due, I received a call from UHC who unbeknownst to me must be affiliated with the specialty pharm I am using, saying that I would not receive my script because they need a PA (prior authorization). I have no relationship with UHC, and I have a completely different health insurer. I contacted my Neuro's office and told them I needed the PA quickly, they faxed whatever they needed to fax on Oct. 14. Yesterday, I called for the status of my delivery, and they said it would be delivered tomorrow. Today I received another call from UHC, saying they didn't receive the PA, so I'm waiting for a callback regarding this.

    Honestly, I am so very frustrated, and I'm tired of making calls. Today was the day I should be injecting my med. It could take as long as 72 hours to get my med if I finally get it at all.

    My questions....Will not taking the med (I've never missed an injection) for a few more days cause problems? and can someone explain how getting a prior authorization actually works? I'm so confused now, I don't know how the actual PA is done. Thanks for any responses.

    I see my neuro next week, and I'm afraid I'm going to lose it for sure, because right now I've had about all I can take. Thanks again.
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    #2
    Hi Melody,

    Sorry to hear you are still waiting for the PA. Incredibly frustrating for sure!

    I had a problem last year with Tysabri. Turned out that because my insurance changed how the med was to be billed, it wasn't being submitted properly. (Because an infusion, this med is normally billed through medical portion of insurance, but my insurance changed that and now goes through my pharmacy benefits). It took several weeks to finally figure it out.

    Originally posted by melody60 View Post
    My questions....Will not taking the med (I've never missed an injection) for a few more days cause problems? and can someone explain how getting a prior authorization actually works? I'm so confused now, I don't know how the actual PA is done. Thanks for any responses.

    I see my neuro next week, and I'm afraid I'm going to lose it for sure, because right now I've had about all I can take. Thanks again.
    Wow - 10 years without missing an injection, I'm impressed While it's best to stay on schedule with your injections, try not to freak out too much (I know, easier said than done), you should be just fine.

    Prior authorization process as I understand it:

    -Script is sent to the pharamacy
    -Pharmacy contacts insurance company to see if drug is approved by insurance company
    -If PA required, insurance company sends PA form to doctor
    -Doc completes form, making case why you need this med, and faxes it back to insurance company
    -Insurance company goes through their process of determining whether or not they approve a med. (This can take a day or two .. or up to a week. It's usually faster if you've been taking the drug already.)

    Here's an article from Consumer Affairs that might you better understand PA's : https://www.consumeraffairs.com/news...ut-040615.html

    Good luck.
    Kimba

    “When you change the way you look at things, the things you look at change.” ― Max Planck

    Comment

      #3
      Kimba,

      Thank you so much for the explanation, I really appreciate it.

      Comment

        #4
        Originally posted by Kimba22 View Post
        Hi Melody,

        Sorry to hear you are still waiting for the PA. Incredibly frustrating for sure!

        I had a problem last year with Tysabri. Turned out that because my insurance changed how the med was to be billed, it wasn't being submitted properly. (Because an infusion, this med is normally billed through medical portion of insurance, but my insurance changed that and now goes through my pharmacy benefits). It took several weeks to finally figure it out.



        Wow - 10 years without missing an injection, I'm impressed While it's best to stay on schedule with your injections, try not to freak out too much (I know, easier said than done), you should be just fine.

        Prior authorization process as I understand it:

        -Script is sent to the pharamacy
        -Pharmacy contacts insurance company to see if drug is approved by insurance company
        -If PA required, insurance company sends PA form to doctor
        -Doc completes form, making case why you need this med, and faxes it back to insurance company
        -Insurance company goes through their process of determining whether or not they approve a med. (This can take a day or two .. or up to a week. It's usually faster if you've been taking the drug already.)

        Here's an article from Consumer Affairs that might you better understand PA's : https://www.consumeraffairs.com/news...ut-040615.html

        Good luck.
        Kimba-Update--I received the PA approval, and med is being delivered. Thanks again.

        Comment

          #5
          Great news! Thanks for the update!
          Kimba

          “When you change the way you look at things, the things you look at change.” ― Max Planck

          Comment

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