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.

The war on (or for) drugs

Maggie is back on the regular antibiotic. This is a regimen now - four weeks on, four weeks off. The "on" was supposed to start at the end of the week, but the doctor said to start it early because Maggie has been below par for about a week. Hopefully the early start will help her fight off any bacterial infection that may come a calllin'.

The drug is inhaled tobrimyacin (Tobi) delivered via nebulizer. (one of four nebulized medications she's on) It takes about 30 minutes to finish the dose and she has to have it twice a day. This is a powerful drug. Since it is delivered via nebulizer the fine mist is all over the room. The nurses have to wear masks while they deliver it. I'm not positive if that's because of potential allergy or too much exposure or both, but that's the protocol and we follow it. 

Tobi is high end stuff and it's ridiculously expensive. The drug store doesn't keep it in stock and they don't even order it until the insurance has approved it. This prescription was approved six months ago, but it had to be applied to the the new insurance with the same company. I picked it up yesterday without delay. Generally the label shows only the co-pay, which is then covered by medi-cal.  For some reason that part wasn't done yesterday and the label had the full price on it.  The clerk looked at it and said to me, "Oh, what do you want to do with this?" I glanced down and saw the price:

$4,890.09. 

 I smiled, patted my empty pockets and said, "well, I certainly don't want to pay it."  She looked confused and I suggested she find out if the coverage went through. I knew it had or it wouldn't have been ready for me. Paperwork fixed. No problem. 

As I walked back to the car I looked down at the bag in wonder. How can this POSSIBLY be that expensive? And what do families do who don't have insurance or medi-cal?

I don't even want to think about that because I think I know the answer.

Something is very wrong with this.