Migraine

I have BCBS of California. New to the policy this year and being a preperation freak I called my mail order pharmacy- Prime Mail- to see what I can get per 3 months. Here is what I was told first, second and third call. First call: Bev "can I get Frova 2.5 mg ? " girl at pharmacy: Yes.
Me- How many at what price?
Girl- 54 pills is a 4 month supply for a $10.00 co-pay.
Me- $10.00? Really I do not think that is right.
Girl Yes that is a generick drug.
Me- Did you spell it correctly it is FROVA. I did not know it was a generic.
Girl- Yes that is the correct spelling FROVA 2.5 mg pill. You can get 54 is a 3 month supply for a $10.00 co-pay.
Me ok, next drug is Dihydroegotamine Mesylate 1mg ampules. I get 5 per month.
Girl- Ok, that is a supply of 15 injections for $2.87.
Me-Are you sure? I pay $150.00 at safeway pharmacy for that drug. Please check that again.
Girl I am pretty sure but I will double check . Let me put yopu on hold I will ask my supervisor.
Me- ok, thanks.
Girl Yes maam that is correct 15 injections for $2.87. Of course we cannot guarantee that price but you can get the med.
Bev- ok
Then I listed the other meds I needed.
On Friday I go to my Dr. and she fills out all the Rx's for three months. I overnight them because I am out of my frova and need it asap. Sat I call ins to see if they recieved it. heres how that call went
Me- I give name ect.. I am new to this ins. I overnighted paper Rx's from my doctor and I want to check the status.
Guy- Yes we recieved them and they are being processed.
Monday I call them for a third time just to double check.
Me ... I am checking the status of my paper Rx's.
Girl- we had to contact your doctor to verify those Rx's.
Me- Verify? why?
Girl- the pharmacist could not read the rx's. we faxed the Dr. but they have not faxed us back. Mabey you need to call them.
Me- Ok.
I called and left a message at dr's office.
Tue I call Ins. co to verify again.
Me....I am calling to see if my dr faxed those Rx's back?
girl- no. You need a prior authorization on 2 of those meds.
Me- Really no one told me that and I have called about these 3 times. Which meds do I need a prior authorization and why?
Girl The dhe45 and the Frova.
Me- really why? I have never had to have a prior Authorization before. In fact I called and the girl told me that Frova was a generic drug. Why do I have to have a aut. on a generic drug?
Girl I will check... Ok You need a prior auth on both drugs but you cannot get a 3 month supply from us. You have to get these on your regular pharmacy and you need a prior auth on both.
Me-really? I have been getting the Frva thru a mail order pharmacy for a year. We are paying almost $4,000 a year to have BCBS and you are telling me that I cannot get these 2 drugs mail order to save me and the insurance co. money?
Girl. Maam we are not your ins. co we are their mail order pharmacy. You will have to call them. Would you like me to transfer you?
Me- I guess.
I get transfered which actually shocked me usually they just hang up on me.
Me-..... I was told by Prime mail that I had to contact you for Frova and dhe45. I would like to know why I cannot get them by mail to save Ins. and myself some money.
Girl You have to go to your regular Pharmacy to get the frova you can get 9 pills per Rx. The dhe 45 your dr needs to call this # and get a prior auth. If she can provide that over the phone it will speed things up.
Me- what does she need to provide?
girl - she has to prove medical necessaty.
Me- ok, so you are telling me that I have to go to a regular pharmacy for the frova and pay full price?
girl no your co-pay will be $20.00 for 9 pills.
Me- how do I know that they told me something totally diffrent last week/ Here is my situation. When I get meds I try to save the ins.co and myseelf as much money as possile. So they would rather me pay $30.00 a pill instaed of getting it through a mail order which is going to be cheaper? So Ins. co have a lifetime maximum $ amount they pay out. If I am going to be on this ins. for 5 years That will add up fast at those prices.
Girl what do you mean maximum amount?Per year?Out of pocket/
Me- No, when you buy an insurance policy the policy has a maximum lifetime benefit that they will pay on an individual.
Girl- I have never heard of that. We don't have that.
Me- Really? well that was what it said when we signed up . So I want to know if that lifetime a millon dollars includes all the $$ they pay for Rx's. Because at those prices It could max out fast.
Girl- are you talking about maximum out of pocket$ per year.
Me- no, forget it. So I need a proior auth on the dhe and I have to get Frova from regular pharmacy?
Girl - Yes

So if anyone has any advise please:

What a mess! Is this employer-sponsored insurance? I wonder if your HR department has an insurance liaison?

Information over the telephone is so inconsistent. It sounds to me like the first girl didn't know what in the world she was talking about. The second girl sounds like she was telling you things that my BCBS would tell me.

From here on, I'd deal only with supervisors. The front-line employees obviously don't know enough to handle your special needs. Get everyone's name, and write a note to yourself after every conversation about what was said. If your doctor has to "prove" medical necessity, that won't happen over the phone. They might have a form. If not, your doctor may have gone through this drill before. But I'm sure it will have to be in writing

I don't have a mail-order option; all my meds come from my local pharmacy. We're on a first-name basis! When I took Frova, BCBS covered 9 tablets a month. If I needed another 9, I paid full retail price. But shop around. Retail price varies from store to store. My store has good prices.

I don't understand the mail order thing. As you said, it seems it would be cheaper for the insurance company, and much easier for you, to get a 3-month supply. It gets old trudging to the store several times a month for refills.

You can get insurance to pay for more than the 9 pills by having your doctor write them and tell them that having the additional pills are a medical necessity. I haven't done that, but I really don't need the additional pills.

I took DHE several years ago. At the time, I was in an all-out war with my prior insurance, and they refused to pay for any of my meds. Even antibiotic for a sinus infection. So I don't know the limits or co-pays on that.

Gretchen in Mississippi

In the past I have had good insurance and gotten 50 pills for a 3 month supply. I just had hoped for what was promised me. I knew the co-pays were off but....
I do not have the strenghth right now to fight the ins. co. All I can hope is I only need 9 per month. However this is the time of year where I get 3 or 4 months of straight migrains.
I cannot tell you how exsausted I am . I cannot fight ins this year and help my health. too. We are paying almost 4,ooo a year now to have this crappy ins.
These migraines havereally put a big cramp in my life. I am so sick of them. If I ever get better and have energy I am going to unleash it in a very positive way to help others with migraine. I feel sorry for the poor saps that catch the wrong side of me. Right now I am just so tired of fighting. I just have to do what is good for me. Crying all afternoon over this #&*!! insurance is just not the ticket.
I asked a pharmacist today the price diffrence between DHE45 and demeral. to be used as a rescue med. to avoid going to the ER. 5 dhe45 shots cost about 167.00 and 5 demeral shots cost about $13.00. Then he sais to me finding a dr to give you the demeral will be impossible.
Now why is that? Are we just all drug addics? I get so sick of it. When I had the 11 months of migraine and I was frequenting the urgent care- About 1 per month. The dr actually told me I had to get a drug contract from my primary care dr before I could come back. Can you imagine if you were a drug addick would you not go to the streets instead of paying 300.00 for a single shot?
If I die I swear I am going to come back and put a migraine in every dr's skull everyday for one month. Every dr who is clueless that is.It is not even going to be a regular migraine. I am going to unleash the vomiting, blurred vision, beat your head on a wall to get relief kind of pain on them.
Ok I guess I am angry. I just want to hear the stupidity come out of their mouth, then point at them and let their pain begin. Then I bet in less thaN 24 HOURS HE WOULD CHANGE HIS MIND ABOUT NEEDING A PRIOR AUTHORIZATION, OR A DRUG CONTRACT. wHAT IS A DRUG CONTRACT ANYWAY? bEVERLY CAN ONLY GET 5 MIGRAINS A MONTH OTHERWISE SHE HAS TO What?? This all reminds me of my good friend who said her great grandmother had problems and they locked her up in an asialum. Then 10 years later her Dr. tested her for thyroid. All in the world that was wrong with her was that she had hypothyroidism. They let her out then. Can you imagine? I feel like her. I have to pay these dr's our lifes savings to help me than I am totally at their mercy. It has been my experience that you cannot change a dr's mind.
I had one dr who is now 4 hour drive frm me. He is an onocolgist and he saved my friends life. She had breast cancer both breasts. Anyway I went to see him Even though I had no cancer he still helped me. At the time I thought if he had not been married I would have went after him. He is what a real dr and a real man should ALL be made of. He is so opened minded. He gave me what I needed and listened to me. Even got me sample meds because I could not afford the triptans.
He is the only Dr that really listened to me. I am going to ask my DH if I can just go see him. Now that I know the better rescue meds I bet he would write me a 6 month or1 years supply. Then if the ins wont pay then I can at least afford to buy them myself. Once he sees that I am not abusing them then he should be ok with it. I am talking about rescue meds for when the triptans fail. Like if I can only get 9 frova then I could take a demerol shot if I run out of frova. If I dont use all the demerol I can throw them out. At that price it will be ok. Now I cannot throw away the dhe45 because it is so expensive. Not that I have run into that but I am just saying if i did.
Ok I am getting really worked up. But I am just mad. I know everyone who reads this has been in the same boat.

Gretchen is right, this is a mess!

I had to get a letter of medical necessity from my neuro before my insurance would cover it. I called his office and asked for the letter, and he didn't have a problem doing it. I guess it's relatively common for insurance to ask for that. My acupuncturist then faxed the letter with her first claim (that's what insurance told me to do).

So, if BCBS does in fact need your doc to prove "medical necessity", I would suggest you ask him to write a letter. Make sure you keep a copy.

I am so sorry you have to deal with stupid insurance problems on top of Fredrick.

Your insruance was - before this problem - allowing you to get 54 Frovas for a 4 month supply? I would say before that you were making out!

My insurance only lets me get 9 Frova at a time. Anything over that I CAN get, but of course I have to pay an additional co pay (for one extra pill, it costs me one extra co pay!)

As far as the authorization issue - I have no heard of needing it for Frova, but possibly for the DHE. Can you look at your pharmacy policy online? If so, you should be able to check it out and get the info on there - in black and white instead of dealing with the lovely reps at Blue Cross (who seems to have a faster turn over rate then any other insurance I know!)

I can look up all my benefits on line - So I was able to scan down and find out what teir each triptan was and preventive, to try and find things that may work and also be less costly for me.

If BC/BS needs a letter of medical necessity - NOW - after all this time - they are blowing smoke - they would have asked for it when you were first diagnosed or when you first started getting these scripts filled on your plan. Place a call to your doctor, then back to BC/BS, get a fax number and have your doctor fax it over, just so they have it on file for any future "problems" they can come up with.

All the doctor really would need to say in the letter (which they would know) is "Bev need X amnt of Frova and X amnt of DHE a month to treat X type of migraines" That's all they are looking for. That and maybe how long you have been under this doctors care.

The thing I've learned about insurance companies is that they will do anything they can to drag thier feet. Once they've started, they won't stop. Yes, some are better then others, sometimes you don't even notice seeing as you are on the member end of things. Sitting on the other side though, fighting everyday to try and get what is fair payment for doctors services, well, let me tell you - it's no walk in the park!

Good luck Bev! I hope you get what you need in the quickest amount of time possible!

This bcbs was not giving me the 54 for a 3 month supply. That was another ins a long time ago. And yes it was nice because if I did not use all of them I saved them over for the next 3 months. However this bcbs did tell me that I could get 54 for a 3 month supply. They came up with that number all on their own. I just asked them what my coverage would allow.
My guess is that I can actually get that many I think the girl that told me that was young and new. So I think she told me the actuall truth. Then the other people I spoke to knew enough to give me the run around.
It is a big issue to me because I have serious migraines and every year at this time I go into sevral months of daily migrain. So if the insurance will only let me have 9 per month and I use 16 I have to pay $224 for the other 9 pills. I priced these at Wal-Mart. I cannot afford $224 a month for 4 or 5 months. The limit that my dr told me I could take was 4 pills a week which is 16 pills a month. so I guess I do not understand why the ins. allows less than that. I can see if they only allow the 16 because that is all you are suppose to take.
Especially when I am forking over $3,800 a year just to have the insurance.
I guess I do not mean to be a witch about it but I did call them before I submitted the Rx to see what my coverage was. That is when they told me 18 pills a month and 5 shots. I even told the girl that I did not think that was correct and she said it was...

Yes they told me I could not get ANY triptans thru my mail order pharmacy I can omnly get 9 perRx thru local Pharmacy. Now what does 9 per Rx mean? I am assuming it means a 30 day supply..

quote:

Originally posted by EileenHOST:
Your insruance was - before this problem - allowing you to get 54 Frovas for a 4 month supply? I would say before that you were making out!

My insurance only lets me get 9 Frova at a time. Anything over that I CAN get, but of course I have to pay an additional co pay (for one extra pill, it costs me one extra co pay!)

As far as the authorization issue - I have no heard of needing it for Frova, but possibly for the DHE. Can you look at your pharmacy policy online? If so, you should be able to check it out and get the info on there - in black and white instead of dealing with the lovely reps at Blue Cross (who seems to have a faster turn over rate then any other insurance I know!)

I can look up all my benefits on line - So I was able to scan down and find out what teir each triptan was and preventive, to try and find things that may work and also be less costly for me.

If BC/BS needs a letter of medical necessity - NOW - after all this time - they are blowing smoke - they would have asked for it when you were first diagnosed or when you first started getting these scripts filled on your plan. Place a call to your doctor, then back to BC/BS, get a fax number and have your doctor fax it over, just so they have it on file for any future "problems" they can come up with.

All the doctor really would need to say in the letter (which they would know) is "Bev need X amnt of Frova and X amnt of DHE a month to treat X type of migraines" That's all they are looking for. That and maybe how long you have been under this doctors care.

The thing I've learned about insurance companies is that they will do anything they can to drag thier feet. Once they've started, they won't stop. Yes, some are better then others, sometimes you don't even notice seeing as you are on the member end of things. Sitting on the other side though, fighting everyday to try and get what is fair payment for doctors services, well, let me tell you - it's no walk in the park!

Good luck Bev! I hope you get what you need in the quickest amount of time possible!

Bev,

I'm so sorry you're having so much trouble with insurance! Who needs Fredrick AND lousy prescription coverage?!?

From my experience, I have learned that you need to have your doctor appeal the insurance's restrictions on your meds. And you need to appeal on your own, too. I know you don't feel like you have enough energy to do all that work, but you really have to! Depending on the insurance's response, you may have to continue to appeal until the insurance company finally allows you to have what you need!

But if you think about it, it costs the insurance company $$ every time they have to review your appeal. If you make enough fuss, it will no longer be in their best financial interest to continue to deny your claims. I guess that's why somebody said "the squeaky wheel gets the grease?"

Anyway, pull together all of your strength and keep fighting this! you can do it!!

jenny

Yes Bev, Most insurances have limitations on triptans (WHY I HAVE NO IDEA!!!!!!! ) but mine allows me 9 Frova in one month.

What about asking your super nice doctor for bunches of samples till you can get this figured out?

Are there other triptans that work for you or just Frova?

I ask because my insurance only allows me 9 Frova a month - BUT - I can get 16 Imitrex in a month and the copay is cheaper too (and Imitrex is going generic before Frova which is awesome!)

Hi Bev,
Oh my goodness, I just went through almost the same thing with my BCPPO this last Friday. I went to the pharmacy and they had problems with the refill, then they talk with the insurance and said the insurance would only authorize 12 per month. They used to give me a 3 month supply. So, I would just fill it and not have to go back to the pharmacy. And my doc gave me a new script for topamax and maxalt and they will not let me pick it up for a month. I never had this happen. It must be something new with BC. So Bev, I SOOOO Feel your anger and frustration. Let me know what happens. I am putting a call into them too. Luckly, I have never needed more then 7 maxalt a month. But, I wonder what if I do?
UGGGGG
Dar

Bev -- do the other triptans work for you? My BCBS paid for 6 Imitrex NS, 9 Relpax, and 9 Frova a month. Imitrex was a $25 co-pay. Frova was $50, and I don't remember about Relpax. But the result was that I got 24 triptan doses a month. I couldn't use one within 24 hours of another, and I had to limit use to 3 days a week, but I didn't run out of triptans over the month.

Now, I'm only taking Imitrex. But BCBS pays for one package of each type per month. 2 injections, 6 nasal spray, and 11 tablets. So I'm getting 19 doses for 3 co-pays. Not the greatest deal in the world, but better than paying out-of-pocket.

I think we can thank the drug companies for some of these restrictions. I haven't studied the FDA-approved prescribing information (labeling) for the others, but Relpax says that the safety of taking more than 9 tablets a month hasn't been investigated. The insurance companies have latched onto that. I'm sure the drug companies could have studied the safety of taking 18 Relpax a month, but that would have meant more expense and a longer delay in getting the drug to market. I think I'd rather have Relpax as an option and fight the insurance company over limitations.

Gretchen in Mississippi

Imitrex pills do not work for me. The imitrex shots last time I took them were about $75.00 a piece.
The Triptans are limited by the insurance companies because they are so expensive. 9 pills at Wal-Mart pharmacy are $224.00

quote:

Originally posted by EileenHOST:
Yes Bev, Most insurances have limitations on triptans (WHY I HAVE NO IDEA!!!!!!! ) but mine allows me 9 Frova in one month.

What about asking your super nice doctor for bunches of samples till you can get this figured out?

Are there other triptans that work for you or just Frova?

I ask because my insurance only allows me 9 Frova a month - BUT - I can get 16 Imitrex in a month and the copay is cheaper too (and Imitrex is going generic before Frova which is awesome!)

My frustration continues. While the mail order pharmacy is tying up my 3 month RX that I now cannot fill thru them. They have to send the paper RX back to me or my dr. to prove to the dr that I am not trying to double fill them. Which I can understand they have to do. However I cannot get in touch with "Amy" at the mail order pharmacy who promised she would fax my dr. last thursday and confirm that I in fact did not fill them. She also promised to mail the paper RX to my doctor. Well, here it is Tuesday and nothing. My Dr. is out on Wed.
Meanwhile I am out of everything except the DHE45 shots that I hate taking. Guess I better be glad I have those.
Anyway..... it is just aggravating to me that I feel like I am not trusted to be an adult with some paper.

Well, Bev, in the edited version of what you know we all want to say - that STINKS!

Can you at least go back to your doctor for a couple samples in the mean time while this whole mess gets worked out?

I mean, what's a girl to do?

Bev,
Have you been able to straighten out any of this???
Cindy