Small Insurance Victory!

I'm so grateful that I've worked in the medical field and been around insurance jargon the last 5 years.  As has been talked about in many previous posts, insurance is crazy and difficult to understand.  Most people don't understand what they can do to try and prevent paying more than necessary, and if crazy charges come back, they don't realize they can appeal those, or at least talk with someone about what's going on.

My most recent "insurance win" is getting all these estrogen patches!  That's 180 of them, and I got them for $10!

When I originally called the pharmacy to see what the cost would be, they told me insurance would cover approximately 16 patches for my $4 copay, but I would have to buy the rest out of pocket and they would be $550.  And that was for a total of #72 patches (what my doctor has prescribed).  This is because insurance companies have set standards for what the believe is good quality care regarding medicines.  Each medication has a 30 day quantity limit that insurance says "we won't cover more than X pills in 30 days because any more than that is unnecessary because we are your doctor  and went to medical school and we know what is best for you."

Well because I knew I had a good reason for needing so many patches, I asked what else I could do and they suggested submitting a prior authorization for a quantity override.  This is something the doctor's office needs to do.

I contacted my clinic and explained the situation so they would be expecting the form from the insurance.  I also stayed on top of Cigna's pharmacy to make sure they sent them the PA to fill out.  I never really heard what the decision was, but a week later received a gigantic box of 180 patches with a $10 bill.  Not too shabby!!!

It never hurts to ask questions, to see what you can do to get a better deal.  The other important thing is to be ahead of the game and ask questions BEFORE you get a bill for $550.  I'm definitely glad I knew about prior authorizations before this experience because I had to do many of them when I worked at the pain clinic.  Doing them can be a pain in the butt so I made sure to profusely thank my nurse for filling out the paperwork so that I was able to save a lot of money!

Also, as a side note, this is only an option for drugs covered by your pharmacy benefit.  Most of the Starbucks plans do not cover any of the injectables under the pharmacy benefit...they go towards medical.  If the drug is something you have a co-pay for, it falls under pharmacy.