Anyone under a specialty medication discount program along with insurance?

unsure what is meant by "specialty medication discount program", but we have successfully used GoodRx and BeforeBreakfastClub to reduce the insurance co-pays on several prescription medications. even amazon is getting in on the game, with their PrimeRx program.

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Loudmouthbass said:
unsure what is meant by "specialty medication discount program", but we have successfully used GoodRx and BeforeBreakfastClub to reduce the insurance co-pays on several prescription medications. even amazon is getting in on the game, with their PrimeRx program.

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So my wife takes Entyvio which is an infusion medication and is sent out by a specialty pharmacy. Basically, she's been on it since January and was under her own health insurance plan with her old job and there is a program that she was enrolled into that made her medicine only costs us $5 per dose. She recently started a new job and is under my insurance plan till her insurance at her new job kicks in after 90 days, but we are having a time getting it to work out the way it did before when her deductible was exactly the same as it is now and everyone we talk to says "everything is approved and ready to go" but no one is making any progress because everyone keeps passing the buck. Wife was supposed to have her treatment on the 24th of June and no appointment has been made to reschedule because of the hold up with the specialty pharmacy not communicating with the discount program/insurance.
 
Sounds like a good application for cobra.
But just a reminder if she swapped insurance plans her out of pocket maximums reset. So maybe she was maxed out in the old plan and the new is starting over.

My wife used to be on an infusion and the drug company had a program where they gave you this card for their drug only ..just to max out your personal oop. It made me realize how dirty the system is
 
Ron said:
Sounds like a good application for cobra.
But just a reminder if she swapped insurance plans her out of pocket maximums reset. So maybe she was maxed out in the old plan and the new is starting over.

My wife used to be on an infusion and the drug company had a program where they gave you this card for their drug only ..just to max out your personal oop. It made me realize how dirty the system is
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Well its crazy because her insurance at her old job started over in December of 2021. She got on the medication in January 2022 and still had not even met any part of her deductible and never had any issue with the discount program covering the cost. I am just trying to figure out what the hold up us because each place we call is placing the blame on the next person. Just seeing if anyone else has had a similar issue with trying to get insurance and these discount programs that only require the patient pay $5 a month because before she left her old job, we called all around and everyone told us that no matter what insurance company she ended up with, as long as she was covered and the medication was approved by insurance (which we have gotten 2 letters saying that it is) she would only be responsible to keep paying the $5 per dose....Just trying to save myself a few thousand dollars is all.
 
Sort of...

Usually you can find discount coupons on the drug companies website. One of mine goes from $200/month with Insurance down to about $40 using the companies coupon. (Good Doc's are usually aware of this and will tell you.)

Have them put the coupon 'on file' at CVS or wherever you pick up your prescriptions and they should apply it each time automatically.
 
Well, after 2 weeks of almost daily calls, we got it figured out...I think.

The discount program kept telling us that the it can't be used towards your deductible, I said, if I had $3000 to give you, I wouldn't need to be on a discount program, so who is this program supposed to help? Got a call on Monday from the pharmacy who was waiting on payment in full to ship the medicine out, and they needed her Co pay ID number, which we have had for 3 weeks now and have given it multiple times to multiple people who have asked for it and they ran it over the phone and it came up saying we only owed $5 and would only be $5 per dose from here on out!
So My wife and I are both glad to have this weight off our shoulders and God is good!
 
I know your struggle, I am on Humira ($11k for 4 week supply) for ulcerative colitis and use the Humira co-pay support program or whatever it's called...Specialty pharmacies (SP) are great or terrible nowhere in between and whatever your primary insurance dictates which SP you use, so no option to find a winner and stick with them. The one I am with currently took over two months to get straightened out with initial co-pay support payment, the kicker was I had to sit on hold while they worked on the issue with the co-payment, hours upon hours of hold music...I get the shakes when I hear it.

It drives up the wall having to keep giving my info. over and over and over agian to each person I talk to...all in the name of safety...

I will say with BCSC insurance high deductible, with an HSA is awesome, doesn't matter what state you have, they consider the co-pay support payments as part of out-of-pocket max and towards the deductible, which is awesome because at about 1.5 refills I meet all of those and then only pay $8 every two weeks for insurance, plus whatever I put in my HSA. So if your wife has the option to get on a BCBS insurance program could be huge savings each year.

Ron said:
Sounds like a good application for cobra.
But just a reminder if she swapped insurance plans her out of pocket maximums reset. So maybe she was maxed out in the old plan and the new is starting over.

My wife used to be on an infusion and the drug company had a program where they gave you this card for their drug only ..just to max out your personal oop. It made me realize how dirty the system is
Click to expand...

The system is a huge dirty wheel of money just getting passed around, My annual insurance "cost" to someone, not me as stated earlier, is about $150k which I have no idea who is actually paying that.

I could get on a rant about the .gov being involved in the medical world (The number 1 customer at any US hospital is Medicaid or Medicare #.gov) and the .gov has a payment schedule that drives the industry to charge what they charge because they know the .gov will pay it no matter what the actual COGs are. for example a device COG could be $10, but the .gov says they will pay $10,000 for it, so the device cost $10k.
 
UNCC-CRAWLER said:
I could get on a rant about the .gov being involved in the medical world (The number 1 customer at any US hospital is Medicaid or Medicare #.gov) and the .gov has a payment schedule that drives the industry to charge what they charge because they know the .gov will pay it no matter what the actual COGs are. for example a device COG could be $10, but the .gov says they will pay $10,000 for it, so the device cost $10k.
Click to expand...
Our experience was the opposite side of that same coin.
In short my wife was on an infusion treatment for ~3 years. Initially it was expensive but reasonable. Our Co-Pay was $100, it was every 6 week treatment so...while it sucked it was bearable. We would get the insurance settlement stuff and the total cost was like $1,400 per treatment but we only paid $100 so...whatever.

Then at a check up visit we were told the infusion program was changing, she would be given the same treatments and same schedule but the charge was shifting, but the good news for us was it would now be completely free with the new "Rumi-Cade card" - the drug she was taking was primarily for rheumatoid arthritis hence the name. They said we would need to use the card for the first couple of treatments each year and then insurance would cover 100% - weird but it was going to be free to us so we were happy. We just had to give them some insurance info etc.
Curious I started digging in. Well turns out at that time our out of pocket maximum was $12,000 per year. The new program didnt qualify for a co-pay. But the treatmens were ~$5k EACH. SO they gave us this card (it had a visa logo along with the drug company logo and everything) - the first 3 treatments we swiped it, cost us nothing, then free. The next yea they reloaded it and cycle repeats.

Customer doesn't ask questions because its saving me money.
The company essentially gave away 3 doses (which they sued to sell for $1,400 each) in exchange for now charging $3,600 more per dose. Doesnt take long to see the profits soar on that one...
 
UNCC-CRAWLER said:
I know your struggle, I am on Humira ($11k for 4 week supply) for ulcerative colitis and use the Humira co-pay support program or whatever it's called...Specialty pharmacies (SP) are great or terrible nowhere in between and whatever your primary insurance dictates which SP you use, so no option to find a winner and stick with them. The one I am with currently took over two months to get straightened out with initial co-pay support payment, the kicker was I had to sit on hold while they worked on the issue with the co-payment, hours upon hours of hold music...I get the shakes when I hear it.

It drives up the wall having to keep giving my info. over and over and over agian to each person I talk to...all in the name of safety...

I will say with BCSC insurance high deductible, with an HSA is awesome, doesn't matter what state you have, they consider the co-pay support payments as part of out-of-pocket max and towards the deductible, which is awesome because at about 1.5 refills I meet all of those and then only pay $8 every two weeks for insurance, plus whatever I put in my HSA. So if your wife has the option to get on a BCBS insurance program could be huge savings each year.



The system is a huge dirty wheel of money just getting passed around, My annual insurance "cost" to someone, not me as stated earlier, is about $150k which I have no idea who is actually paying that.

I could get on a rant about the .gov being involved in the medical world (The number 1 customer at any US hospital is Medicaid or Medicare #.gov) and the .gov has a payment schedule that drives the industry to charge what they charge because they know the .gov will pay it no matter what the actual COGs are. for example a device COG could be $10, but the .gov says they will pay $10,000 for it, so the device cost $10k.
Click to expand...
So my insurance (which my wife is on with me) is actually BSBS, but so was hers when she was at her old job. When she first got on Entyvio, we got approved by insurance and the Entyvio connect discount program all in the same week. Never had to call a specialty pharmacy to give permission to ship medication to doctors' office or anything. This time around, not so much... I am glad that its all taken care of now though... My only question now is, should I just keep the wife on my policy even when she is eligible at her work, because I dread going through this process again. I think her new job offers United healthcare, which I have been told is pretty good insurance to have. Her current employer will pay 70% once her probation period is up, so I guess depending on how much that is going to be as well as her deductible/coverage, we will just have to see...
 
IMO I would stay, and next open enrollment speak with someone from the insurance company, not HR they won’t know the details she’ll need to know about the process and then consider switching.

I hate switching insurance.
 
UNCC-CRAWLER said:
IMO I would stay, and next open enrollment speak with someone from the insurance company, not HR they won’t know the details she’ll need to know about the process and then consider switching.

I hate switching insurance.
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I know man, This last round has been a struggle and I just don't really want to go through it again, although if her new insurance is going to be good and have a lower deductible and isn't going to cost her an arm and a leg, it would be tempting.
 
Funny how only after being under my insurance for a little over a month, my wife gets a letter from BSBST stating that the specialty pharmacy (that we JUST GOT to approve her medicine after weeks of back and forth) we use is no longer going to be in network starting Sept 1st and that we have to find a new pharmacy which means, we might have to go through this whole process over again...
 
UNCC-CRAWLER said:
I would get on the phone right now with BSBST, and find out which one is in "The Network" aka which one is owned by the same people that own them.
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Exactly, I am getting ready to email my HR lady (who was tremendous throughout this whole ordeal) and let them know and see what she says as well as calling BSBST
 
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