My Insurance Company

Hi all,

I am due to start tx as soon as my meds are approved. I am a genotype 3 stage 0 and my doc says that I have an 80-90% chance of reaching SVR within the first 4 weeks of six months of tx. I thought of postponing tx and waiting a year or two because of the harsh side effects but I just really want this gone and out of me. I have 3 kids, 11, 14 and 16 and I dont want to pose any threat to them. I just think about if we're in a car accident together and we all get seriously hurt how my blood could so easily mix with theirs. I am 40 years old and the best I can figure was I got HCV from getting a tattoo when I was 19. Ive never done IV drugs and if it wasnt that it would have to have been from a doc or dentist. Who knows, who really cares I only know that I have it and I want it gone.
  Now here is my problem. I am trying to get my script filled. I call my insurance company, Anthem blue cross, and they tell me I HAVE to use Precision RX for my meds. I call them. They are trying to get the prescription from the doctors office, they finally send it and the Pharmacy cant read the directions. So I have been back and forth for about a week now between the pharmacy and my doctors office. Today i decided to ask Precision rx about their cash cost. I have seen it on my insurance companies website for like $1800 month at walmart and Kroger Pharmacies but anthem is telling me I have to use precision rx. She came back with a total cash price and it is a whopping $2800!!! Now the insurance company is telling me that I will either have to pay the $60 a month copay or 20% of the meds. They wont know until the prescription is filled. Now why would they make me use a pharmacy that raises the price like $1000 when it could be cheaper somewhere else for both of us? Can anyone offer any advise or personal experiences on this? Does anyone have the same insurance company? We chose the better plan this year because we knew I would be doing tx.

Thanks in advance. Ive learned so much from this board that I am calmer now about taking the meds and I am preparing my family for the worst.

Thank you all

  

[jmjm530]

I have 3 kids, 11, 14 and 16 and I dont want to pose any threat to them. . I just think about if we're in a car accident together and we all get seriously hurt how my blood could so easily mix with theirs.'s's
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apologies for going off-topic, but your reason for treating stuck out like a sore from for me.

your odds of giving your children HCV in the next few years ( until better drugs are available) are  probably similar ( to use Dr. Dietrich's words in the expert forum) to getting hit by a meteor.

as someone with zero liver damage, and concerned about their children, you should seriously consider how the side effects of treatment will affect both you and your children.

[jmjm530]

I re-read your post, and see that you are a genotype three. As a genotype three, standard treatment is  24 weeks as compared to 48 weeks for genotype one. it's even possible, to shorten treatment to 12 or 16 weeks assuming you have a very low pretreatment viral load and that you become undetectable by week four. because of this, the risks versus rewards argue more in favor of treating than if you were a genotype one. as to the prescription thing, it's not uncommon for the insurance company to specify a pharmacy they have contracted with.

[Rain6866]

I have considered and have went around and around on the subject. Its been almost a year since I was diagnosed and I was told that the longer I wait, the older I get and the harsher the tx maybe with more age.
  Maybe it is a small chance but one Im not willing to take. We travel often and on very long trips plus I live in Myrtle Beach where if it rains there is 25 accidents in the first 10 minutes of rain. Dont get me wrong. I know what your saying and I appreciate the advice more than you know. Ive just thought this out long and hard and I have been very upfront and honest with the kids about everything. They know the sx and they know what this disease does. It was a family choice for me to go ahead and begin along with the doctors advice. Ive even taken the kids on appts with me.
they are strong and have been thru a diversity of obstacles in their lives. Also one of the closest drugs to coming out is one that is for people that have already been thru tx and have not reached SVR. Thats supposed to be early 2010. Either way I have to undergo tx. This one maybe a lot worse but at least it will be over with and with Gods grace I will reach SVR.

Thank you so much for your concern.

[Rain6866]

I was typing as you were to the second comment lol. Thank you so much and I hope I am one of the lucky ones that will have my tx shortened.

[jmjm530]

by the way have been in those Florida flash floods and they can be pretty scary. Given that you do a lot of traveling, my suggestion is let to the wife drive while you're on the treatment drugs. we've had a number of accidents reported here directly attributed to the drugs. I remember myself yelling all kinds of expletives at a couple of 80-year-old lady's in a car next to me one day while I was treating. it was something we call it here "riba rage" related to the drug ribavirin. After that incident, I kept my driving to a minimum.

[Rain6866]

Thanks, I dont plan on doing that much driving but I am the wife lol.. My doc doesnt expect my to have to much of the riba rage since I am already on an antidepressant that I started 4 weeks ago. He plainly said if the "b****iness comes we will handle it. My hubby was glad to hear that lol..

[jmjm530]

it's good that your hubby is getting a heads up and that he has a sense of humor about it. if I may ask, what kind of doctor you treating with? ideally, you will be treating with the liver specialist ( hepatologist). Next in line, would be a gastroenterologist with experience in HCV treatment. You do not want to treat with a general practitioner, no matter how nice a guy (or gal) he or she is. The treatment landscape is constantly changing and you really want someone on top of the latest protocols but equally important you want someone who will aggressively and appropriately deal with any side effects. Going on ADs prophylactically seems like a good start given the concerns you voiced in your profile.

I'm assuming you quoted your doctor and correctly, but just to clarify, it's not "SVR" that happens within the first four weeks, what you're looking for is to become undetectable within the first for weeks. Regardless of how soon you become undetectable you will still need to treat for a minimum of 12 weeks with the usual protocol being 24 weeks.

Two things you must discuss with your doctor prior to treating are getting a week 4 sensitive viral load test ( you want it) and in making sure the doctor will intervene with helper drugs (like Procrit,epo) instead of reducing your dosage. The other thing -- I guess that's three things now ;) -- is you should make sure you are put on weight-based dose of ribavirin as opposed to a flat 800 mg dose

[Rain6866]

Ok lets see if I can answer all these questions without forgeting anything. First I am treating with a gastroenterologist He was recommended by my reg doc after he sent me to the hepatoligist that literally was very unorthadox and basically told me to shut up that he knew what he was talking about and I didnt. I was angry. Thats why I was asking questions and it was ME that had this.. not him!
  
Yes it was undetectable and not SVR. This all is still new to me and I get confused sometimes. Sorry. I have had a viral load test and he did say another will be in 4 weeks of beginning the meds. I also asked him about the rescue drugs and he said "Oh H*** yeah" He is very outspoken and upfront and takes a lot of time with me on my visits. Thank God for you all on this board because I have learned so much. when I went for my last visit I had a whole page of questions and he gladly answered each and everyone to his fullest extent while not worrying about the time it took. He seems very capable and kinda nice on top of it. I only want the best care i can get because I love me lol.. i will ask him about the riba dose and make sure that is what it is.

Thank you for being so kind and spending so much time with me and helping me

[Proactive]

Welcome to the happy heppers hideaway....Did I hear right, Myrtle Beach? Seems I kinda remember spending 10 years there in my youth...(lol) As I recall, there was a bar, think it was named Duffy's, right next to the Bowery, friendly little place--a place where everyone knew your name...And then there was the time I got a tatoo sitting at my kitchen table on my birthday....always wondered about that tat!!

Best of luck with your treatment,
pro

[Proactive]

now the memories are flowing (g)....Is River city cafe still there? That place had the best onion rings in the world!!!.and throwing the peanut shells on the floor, large fun..sorry for barging in

[Marc1955]

To get back to the original question . . .

My meds cost $2,300 per four weeks. So that at least gives you a bench mark.

I'm really surprised that Walmart would handle something like this. These are speciality pharmaceuticals. For one, the interferon needs to be refrigerated and handled with great care. It's not something you can pick up anywhere. I could be mistaken, but it surprises me.

And the real question is when you looked up the price, were you comparing apples to apples? These are a number of different products with very similar sounding names. In fact, you should triple check that the pharmacy understands what your doctor as prescribed.

All that being said, I think you're right there is an injustice. Unless the terms of your insurance state that they can steer you to a pharmacy, it sounds pretty awful. Was an agent involved in selling you the insurance? These folks can often be helpful in working these things out.

[Rain6866]

They are both still here. Its changed a lot around here. The pavillion is gone and we had the new hard rock park which filed bankruptcy after its first season. Stupid us bought season tickets that were good for a year for $800 and we lost out on them (theres 5 of us)  you can go to myrtlebeachonline.com and broadwayatthebeach.com to see a lot of things.

Enjoy

[Rain6866]

I know Ive looked up pharmacies in the area and those contained walmart and kroger as well. Yes I had the med names from the doctor so thats what I looked up. My insurance is thru hubbys work so no we dont have an agent. I just hope to hear that I only have to pay the copay. If not Isobella posted me some links on another post that maybe very helpful in finding someone to help out. Just cross your fingers for me.

[granitekonig]

My advice to you is to read through as many posts and threads on here as you can over the next few days before you post again. Not that we don't want you to post...but you will answer SO MANY of your "new hep" questions so fast. Jot down notes and what the abbreviations mean. Welcome! ;)

[CoWriter]

If you're using Pegasys, call Pegassist.  They will verify insurance coverage, co-pay, and find the best pharmacy for you.

http://www.pegassist.com/pub/hcp/default.asp

Co

[IMstacie]

Rain - my husband has Anthem Blue Cross and he will be using Precision RX.  It took a while, longer than a week, but once it is in place is moves smoothly.  Plus, it nice to have it delivered to your door.   I on the other hand have HealthNet.  I had to use a different pharmacy and it took me 3 months to get it straightened out!  Just stay in contact with both your doctor and the pharmacy, calling daily if necessary.

[Rain6866]

Thank you Yuk. Does he have to pay the copay or does he have to pay the 20%. Precision seems to be on top of things and looks like my Doctors office is the one falling behind. I have been calling them daily.. Back and forth between them. The doctor finally sent the prescription and they couldnt read the directions so its been 3 days trying to get the directions into Precision RX. Im starting to feel like they are giving me the run around.

[Headfridge]

I have been using Anthem/Precision Rx since Dec. 07.
My co-pay was in the $470.00 range per month (20%) for the first six months (I think) and then dropped to $20 per month.  With the new year, I'm back at the higher co-pay.
Precision Rx works great, Anthem can be problematic.  You have to stay on top of them.

[nygirl7]

I wouldn't really worry about your kids getting hepc from you from a car accident...there are about a million ways that are more likely than that.  But, if you want to treat and that decision works for you then go for it.

One good reason you treat now is that on rare occasions a geno3 can be almost harder to treat than a geno1 - best sometimes to find out now that way you would still have time in the future to change and extend treatment.

Considering the great amount of expense that the drugs cosst - $60 isn't really all that bad. It doesn't make sense to me why you'd HAVE to use a more expensive company except..........I'm sure that they want to make as much money as you can.

Anyway I just wanted to say - make sure you ALWAYS refill your script a week or two BEFORE you run out.....just in case!  A few times the pens have jammed up or broken or the meds just weren't at the pharmacy when I went to get them...all sorts of odd things.  You want to make sure that you have at least one at home in the fridge for the following week just in case.........it will save you a lOT of grief later on (and of course if you do it that way it will never happen and you will be fine ;)

PS Yes it was undetectable and not SVR

Don't worry about saying SVR instead of UND - we all get what you mean and we were ALL new at one time and said the same incorrect verbiage and newbie mistakes.  If you have a question just ask it.......the more you learn the better off you will be.

And don't forget get copies of ALL of your test results and learn how to read them! At first you can post them in here so people can explain them to you, in no time you'll understand it all you'll see.

[Rain6866]

Headfridge -  Is it because of your deductable your back on the higher amount? I know my deductible is $300 this year because we switched to the better plan knowing tx was coming. They told me it would be the $60 or 20%.. Im praying for the $60 but I would still have to meet my deductible of $300 which would probably be in the first month of meds.


NYgirl - A car wreck was just one instance I could think of. I want to do the treatment and get it overwith. I want this gone while the doc says its the best chance. I have no liver damage in fact he said if he didnt already know I had it he couldnt have told by looking at my biopsy so i just want to get it gone before taking a chance of liver damage.

thank you for the excellant advice on ordering my scripts. I had never even thought of that. Im sure I would be panicing and driving everyone insane if I was to run out lol..

I have been asking a few questions and my doc was really surprised all that I have learned. I learned it from all of you. I am so grateful for this board because without it I would have known nothing. The people at Be in Charge say I am ready and well prepared to start tx. That also is because of you all. I also have copies of all my test on the way. As soon as I get them i will post it.

Thank you all so much..

[Headfridge]

It is indeed because of my deductible amounts.
My out-of pocket expenses for the first year of treatment was several thousand dollars.
That's factoring in co-pays and deductibles for labs, radiology, specialists, etc.
Before you get too excited, do understand that your coverage could vary significantly.
However, even with good insurance, this can be a spendy proposition.

Here's wishing you the best of luck.

[njlady365]

Rain, here are my 2 cents - i'm not familiar with precisionrx, but i was on their website and it seems that its a mailorder pharmacy that is contracted with your insurance company. most ins companies only contract with one mail order company.

my suggestion is get on the phone with your insurance company's member services (ugh, i know) and find out from them what exactly your out of pocket expenses will be. you will probably have to pay your annual deductible (if rx applies to it) and then pay either the flat rate, or the coinsurance. again, member services will be able to tell you specifically how much. if they don't, keep bugging them until they do. ALWAYS get the name of whoever you speak to. and if you aren't satisfied with what they tell you, ask to speak to a supervisor, and get their name as well. even though they may have hundreds of people working there, they can track down the person giving you the info because they note your account with all inquiries. but always keep a record of who you uspeak to as well.

whenever you call any pharmacy, mail order included, they will quote you a price they'd charge you if you didn't have insurance coverage. your insurance company has contracted with pharmacies for set rates, so what the pharmacy will charge your plan will be a lot less than what is originally quoted. and i believe all mail order plans will only give you three months at a time. (take a glance at any of your EOBs, you'll be amazed at the difference between what a provider charges and what is contracted.)

personally, my plan will charge me a flat $200 for a three month supply thru our mailorder company, even though the coinsurance would be more. its because of the contract the provider has with my plan and because my plan has a cap. this is an incentive for members to use the mailorder because it saves the insurance company $. my plan also allows me the option of using a retail pharmacy like walgreens, walmart, etc, if I choose, but my out of pocket will be over $700 a month.

most people don't know or realize that it is the employer that drives what benefits are available to you. they are the ones that choose what is covered, plus the levels of coverage the insurance company offers employees, based on how much they paid out in claims the previous year. and how much they're willing to pay this year. so if your benefits blow, blame your employer, not the insurance company. mine are the worst i've ever heard of (richest plan has a $3k deductible a year, AND i work for the stinkin insurance company.)

Oh, and all pharmacies are regulated and have to meet federal mandates, so they are all capable of handling ALL medications, not just the basics. this includes walmart, sams clubs, supermarket pharmacies, the local mom & pop pharmacy around the corner as well as all major chains.

Hope this helps. and i wish u well on ur treatment!
xoxo

[IMstacie]

The pharmacy will tell you exactly what your co-pay is.

[Rain6866]

That helps me sooo much! Thank you. I did get some really good news today. My riba is going to cost me $15 per month. Im still waiting on the pegintron pricing because my ins comp requires a pre auth (I could have told them that) which they faxed to the doctor today. Of course I cant miss a day without calling that office either so I left a voicemail for them to get it hopping.. they are probably sorry they ever saw me lol..

Thank you all for the great advice. Your helping me more than you know.