Thursday, December 13, 2012

Please hold for the next Circle of Hell

There s new term out in the world and it seems to be quite popular: Specialty pharmacies. Never heard those words together until about a month ago, now I hear them every day. And every day I cringe just a little bit more. Apparently these "specialty pharmacies" only work if you don't have special health care needs.

I realize that begs the question, why would one need special medications from a specialized pharmacy if they didn't have special health care needs? Beg away. I can raise many questions, but despite my greatest efforts, I cannot find any answers.

We received a notice from Anthem Blue Cross a while back that certain medications could be obtained through their "specialty" pharmacy. It was touted as a service to the insured, which of course it was/is not. Rather than utilize the typical drug store and the pharmacist we are familiar with, Anthem wanted to make our life easier by having me order some of the medications from this "specialty pharmacy" and the be delighted when they were shipped to my door.  I couldn't do this with all the medications, mind you, only these "special" meds that warranted a "specialty pharmacy." That meant ANOTHER layer of hassle because I still had to get Maggie's "regular" medications through my neighborhood pharmacy. Hardly a service.

That happy "service" announcement was soon changed to a warning: "If you don't use our "specialty pharmacy" you will pay more out of pocket because your co-pay will be higher." I smirked at this one because Maggie's co-pays are paid through Medi-cal, the state program for the disabled and/or indigent. These amounts are not your basic $10 or $15 co pay either, the co-pay on one of these meds is something like $3500/month. The other is about $400. Yes, those are the monthly co-pays. Needless to say, I have to utilize the medi-cal plan or we could not afford the meds. In order to take advantage of medi-cal I have to get the drugs in California from a pharmacy that will work with the two systems. So I ignored the warning.

Now it's mandatory. In the space of just a few months, this new "service" is now required. This is problematic for me because the "specialty pharmacy" does not understand what medi-cal is and the chance of of the two working together is slim to none, especially since the required pharmacy is in Florida and medi-cal applies only in California.

I called Anthem last week and explained my dilemma. The guy gave me a waiver for this month, but said it was a one time deal. I would have to go through the "specialty pharmacy" beginning in January.

I contacted the "specialty pharmacy" and attempted to explain my dilemma. It was incomprehensible to them. They said, I would have to pay the co pay and then be reimbursed by medical. Nope. Medi-cal doesn't do reimbursements. I gave them all of Maggie's medi-cal information and the "specialty pharmacy" woman kept asking me for the phone number on the card. There is no such number and even though the card was in my hand, she could not believe that, saying all insurers put a contact number on the card. I told her, you don't understand, medi-cal is not an insurance company, it's the state of California. She said that doesn't make any sense. I pointed out it has worked perfectly well for several years until this "service" turned mandatory.

Maggie is a round peg and this is a very square hole. But she is not unique. She has complex health care needs, as do millions of other Americans. If her (ridiculously expensive) private insurance makes it MORE difficult for someone with complex health issues to get medication, one could wonder about their ulterior motives.

After my 4th or 5th round of calls I did learn that there are exceptions and if Maggie's doctor could fill out a form - one for EACH medication - perhaps Maggie will be excused from the "specialty pharmacy" rule.

Excellent. I got the forms and the doctor signed them on Tuesday when we had a regular visit. I met with the pharmacist to update her on all of this and then the other shoe fell.

Novartis, the manufactures of one of these medications just issued information to pharmacists to advise their patients who use inhaled Tobrmyacin (the crazy expensive one) that effective February 1, they will only dispense this medication through "Specialty pharmacies."

So Maggie  may or may not get "excused" from the specialty pharmacy  program through Anthem, only to be back in it because of the manufacturer.

My mistake, it's not a round hole; it's a Circle of Hell.


  1. You should trust and believe me that in this very moment I am weeping in frustration at your and my own similar yet different problem. Oh, my god.

  2. There is a special hell for people who write these policies.

    I'm fighting my own stupid horrible pharmacy battle right now, on behalf of my brain damaged father, and it just makes me want to scream.

    Perhaps you should see what it takes to get a pharmacy designated as "specialty."

  3. As a parent with kid with special needs I keenly feel your frustration. Anathema is just part of the problem and clearly insurance companies are cherry picking for the patients who need preventive and low cost care to provide full coverage to line the pockets of their CEOs and shareholders.

    Those who actually could use medical assistance should not be subjected to this pay out of pocket special treatment and never be reimbursed by the state. Really just put it on your taxes since it will put you over 7.5% of AGI and we all make so much to make this practical and not lead us to bankruptcy, etc. Not a slippery slope, I agree a personal fiscal cliff to a circle of hell.


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