Health Boards
Wed-26-06-2019, 17:42 PM
Yes, it's very difficult to understand.
Stelara was buy and bill. The coverage was through our medical insurance and basically the hospital buys it (at a reduced cost I imagine) and then sells it to me through my insurance. That is why I had to go to the hospital for those injections.
Cosentyx was through our prescription insurance (NOT medical insurance) and that insurance required we use their specialty pharmacy. The co pay was through Cosentyx and after the co pay they had a credit card additional co pay if needed PLUS my prescription insurance had a program called "save on" which agreed to cover any costs not covered by any of the co pays.
Taltz is also through our prescription insurance however, it looks like the specialty pharmacy that the doctor sent it to will handle it (they sent the Cosentyx through the same one but our prescription insurance said no, we had to use theirs) and they have given me the info to call Taltz to apply for co pay. If approved it's the $5, if not approved it's $25. I explained to them that our prescription insurance required the Costentyx to go through their own specialty pharmacy but they are sending out the Taltz and didn't think it was a problem, let's hope they are correct.
So I don't understand any of that! Three biologics all handled differently by insurance and how they bill. I filed medical insurance years ago for a hospital but things were MUCH simpler then. I believe that a lot of it has to do with the companies that are making the biologics and how they manage their co pays since it seems each of them offer some type of co pay program. Then the doctors find the "work around" on how best to bill it to the patient's insurance to make the most of the coverage. Or something like that anyway, I'm just glad I no longer work in insurance as it's way too complicated anymore!
But hopefully this will be the one that works for me.
Stelara was buy and bill. The coverage was through our medical insurance and basically the hospital buys it (at a reduced cost I imagine) and then sells it to me through my insurance. That is why I had to go to the hospital for those injections.
Cosentyx was through our prescription insurance (NOT medical insurance) and that insurance required we use their specialty pharmacy. The co pay was through Cosentyx and after the co pay they had a credit card additional co pay if needed PLUS my prescription insurance had a program called "save on" which agreed to cover any costs not covered by any of the co pays.
Taltz is also through our prescription insurance however, it looks like the specialty pharmacy that the doctor sent it to will handle it (they sent the Cosentyx through the same one but our prescription insurance said no, we had to use theirs) and they have given me the info to call Taltz to apply for co pay. If approved it's the $5, if not approved it's $25. I explained to them that our prescription insurance required the Costentyx to go through their own specialty pharmacy but they are sending out the Taltz and didn't think it was a problem, let's hope they are correct.
So I don't understand any of that! Three biologics all handled differently by insurance and how they bill. I filed medical insurance years ago for a hospital but things were MUCH simpler then. I believe that a lot of it has to do with the companies that are making the biologics and how they manage their co pays since it seems each of them offer some type of co pay program. Then the doctors find the "work around" on how best to bill it to the patient's insurance to make the most of the coverage. Or something like that anyway, I'm just glad I no longer work in insurance as it's way too complicated anymore!
But hopefully this will be the one that works for me.