Dealing with insurance...

Well, several weeks back I made the decision to take a higher paying job. I shifted the new companies desired start date back some so I could get my infusion close to me departure with my past employer. This was going to leave me several weeks to get my infusion's (inflectra 10mg/kg 4wk) prior authorization to be fully processed and approved. Now I'm sitting here many weeks later, already well past my infusion due date, without them even having logged the authorization request in their system. Dozens of phone calls have shown to be useless. The kicker is my Dr prescribed me Budesonide as a hope to hold me over until the infusion finally gets approved (hopefully) and the insurance company will not even allow this prescription without prior authorization. So, I'm now stuck with no options other than paying for stuff out of pocket or just being forced to take prednisone for a while.

So, my word of advice for you UCers out there is, DO NOT pursue/accept any job that offers Cigna insurance. I selected their most premium plan offering which comes with over an $8000 deductible for just myself and this is how things are going. I never had any issues when I was with BCBS.

Damn! Are you having symptoms? I would call every day also plus start the paperwork for filing a complaint with the insurer commissioner for your state and let Cigna know you are doing so.

Can you check with your dr? If you’re starting to flare, as a last resort you could try the hospital as I don’t believe they need prior authorization. It would depend on your health state whether they’d admit you or not and I don’t know if they’d give you an infusion in ER. Your dr needs to advocate for you in this instance and get the insurance to give you emergency authorization before you get in bad shape AND develop antibodies after being off remicade too long. How many weeks past infusion are you?

straydog said...
So your dr sent the order & CIGNA has ignored it? Wow, so sorry to read this has happened. I would call them every day, that's just me.

You can download GoodRx on your phone & it should save you a good deal of money on your script, this is beyond ridiculous.

Keep us posted.

Yes, they have ignored me. I have called in numerous times, and I am just told the authorization department takes a while to process and upload the faxes they receive. All insurance companies seem to have it setup to where you cannot communicate with this authorization department. Only your provider is allowed to be in contact with them. My provider has called numerous times to confirm delivery of the authorization request. There is no care or desire on the insurance companies' part to try and expedite the process or to look into what needs to be done to make things actually get done without any additional delay. I was told the only way it would get processed any different than their standard rate is if it was submitted as an emergency authorization while I'm in the hospital.

With GoodRX, Budesonide is still $400 for a 30 day supply. For that price, I'll just take Prednisone because it's more effective.

FlowersGirl said...
Damn! Are you having symptoms? I would call every day also plus start the paperwork for filing a complaint with the insurer commissioner for your state and let Cigna know you are doing so.

Can you check with your dr? If you’re starting to flare, as a last resort you could try the hospital as I don’t believe they need prior authorization. It would depend on your health state whether they’d admit you or not and I don’t know if they’d give you an infusion in ER. Your dr needs to advocate for you in this instance and get the insurance to give you emergency authorization before you get in bad shape AND develop antibodies after being off remicade too long. How many weeks past infusion are you?

I'll have to look into the insurance commission. Based on other review and complaints I am seeing online; I do not suspect much is going to change with their business practices. I have been calling every day and I go through the same conversation every single time. I have talked with multiple managers and it all eventually just ends with them saying that you just need to give it more time. No care or urgency on their part when I explain this is a time sensitive matter.

I am over a week and a half past my infusion due date. But I am still stuck in the early stages of the entire process. I am still waiting for the auth to be uploaded in their system, reviewed (they claim this can take up to 14 days), and then I have to convince the infusion clinic to get me in ASAP. My Dr is trying to help but it doesn't seem like they are going to do much more than confirm the request has been sent and prescribe other prescriptions to try and buy me more time. I am only having mild symptoms at the moment. I'm just someone who can go from being fine to in the hospital really quick. My initial disease onset started with me being completely GI symptom free to bleeding to death in the hospital in only the matter of a few days.

Going to the hospital would be an option once I get worse. This way they could actually justify admitting me. I obviously would prefer to avoid letting things get that bad.

Sara14 said...
That all sounds awful, including an $8,000 deductible (I keep hoping that was a typo and should read $800!!!).

It's actually $8150 with a $3000 yearly premium. If I were on a family plan, it would be $16000!

Cost plus drugs https://costplusdrugs.com/medications/budesonide-dr-3mg-capsule/

Has 3mg budenoside for $16.75. As I recall the optimal dose was 9 mg but you could take 3 I’ll bet. It would just triple the cost but that’s still a ton cheaper. I used costplus just lately. Takes about a week for them to process and ship.

Im so sorry for all the headache. I know the frustration. When I was in the hospital I had to stay an extra day because insurance wouldn’t approve the medication and my dr wouldn’t allow me to leave without it. So the insurance would rather pay however many hundreds/thousands of dollars it was for another day than just approve a medication. It was frustrating and totally ridiculous. Filing complaints doesn’t get anymore action (I did file one) but it does make the insurance move a little faster I think. And it gave me a lot of satisfaction!

Please keep us updated.

Sorry you are going through this too. I just switched to Cigna because my husband changed jobs, and so got to go through it twice this year!! First with CVS/Fidelity, who were actually worse than Cigna. I really think the stress of all of this is making me flare, which is not helping either. Wish I had some words of wisdom. It did take several weeks. I hope you can get it sorted out soon.

That's insane. I'm so sorry. I remember BCBS gave me a number to their authorization department before. I have several bottles of unused budesonide here. Too bad I cannot share them.

That's great to hear. Good job advocating for yourself.

Glad you got it worked out!.

Thank you for posting how it was resolved.

Clo

Did you check the pharmacy side of your insurance? It should state in your insurance book exactly how they pay for your infusion medication. I don't know of any company that pays 100 percent...so I'd get that info and dispute it.

I hate insurance

My Cigna plan has the drug being covered 100% outside of the deductible requirement. In my opinion this is a strategic move on their part, as I'm on a very high deductible plan. The math works in their favor when they do it this way.

The cost is going to be less for them by covering the drug 100% outside of deductible requirements. It forces for me to pay out of pocket for all of my infusions to be administered before I finally meet my deductible. So no matter what they get their $8000 and they ensure the cost and burden of the $8000 is put completely on me rather than allowing Pfizer's Encompass plan to financially assist. They are smart enough to know this will force people to want to consider other options or not take on other large medical expenses until one progressively meets their extremely high deductive over the course of the year.

How much were you billed for the infusion? Like I said for me the infusion charges are a fraction of the med cost.

Clo -- my question was for Curious Crapper

Curious Crapper -- did you get this straightened out? What were you billed for the infusion?

I am hoping CC got this straightened out.

When I was on Remicade my insurance paid the contractual amount agreed upon with the facility. After my deductible was met I paid zero for my infusions.

I received EOB's that gave an itemized list for each charge & what was paid.

Something really sounds off here, but I hope it's been taken care of.