Insurance whiplash

I didn't anticipate writing another blog post until my next oncology check-up in February. But Penn State's switch from Aetna to Highmark on January 1 has created medication chaos for me. I did not think I would have to spend hours making phone calls and writing emails to make sure that my very expensive targeted therapy medication (Tagrisso) and my blood thinner (enoxaparin/Lovenox) will be covered and that I have no gaps in doses. It has been very time-consuming and stressful.

The short story is that I will still pay nothing for Tagrisso and I have 2 months of enoxaparin at the price I was paying with Aetna ($41). Here's the longer story.

Due to the New Year's Eve holidays, I first called my oncology nurse on January 3 or 4 to get a new Tagrisso prescription submitted and pre-authorized with Highmark. Once it was approved I called the mail-order specialty pharmacy (Accredo) to find out the cost. $5000 per month. I was livid. After several rounds of phone calls with Highmark and Accredo and more than an hour of panicking about the new price, I learned that the cost will still be 0 because, unbeknownst to me, I am already enrolled in an AstraZeneca program that pays for up to $26,000 of the drug cost per calendar year, plus another program that decreases the co-pay to nothing after the $26,000 is used up. The inaccurate information about the cost caused unnecessary stress. 

By the time this all got straightened out, I had one week's worth of Tagrisso left, even to last until Wednesday, January 11. (It's ok to miss doses, but I'd obviously rather not.) It was supposed to arrive on Monday, January 9. However, that day I got a UPS notification that the delivery was delayed, with no updated delivery date. I spent nearly 30 minutes on hold with Accredo on Wednesday, only for the rep to tell me that she contacted the "tracking team" but they didn't have any information and I would have to call back later. So I had no idea when the Tagrisso would arrive. For all I knew it could be days. 

But that was only the first medication problem I dealt with on Wednesday. The bigger problem was that I went to CVS that morning to re-fill my enoxaparin prescription. I still had 10 days' supply left, so I wasn't worried about being able to get it filled. But then the pharmacist told me the new price would be $480 instead of $41. And she said I'd have to get a new prescription and order it from Accredo because Highmark considers it a specialty medication that you can't just pick up at the pharmacy. I flipped out and started calling Highmark and Accredo. They all confirmed it would be $480. But after additional phone calls, someone told me it would actually be $200. I thought that was my only and best option, so I had my oncologist send a new Rx.

Leland recommended that I contact Jenn Baka, the chair of the Penn State Faculty Senate's Faculty Benefits Committee. So I emailed her and she immediately put me in touch with a senior HR rep, who connected me with Jennifer, the Highmark benefits consultant who works with PSU. Jennifer made a lot of phone calls for me and helped sort things out. First, she found out when the Tagrisso would be delivered: Thursday. It arrived in the evening, just in time so that I didn't have to skip a dose. Medication deliveries with CVS/Caremark specialty pharmacy were never late. Accredo's shipment was two days late. Jennifer reportedly told them they cannot be late on shipping medication to patients. 

Regarding the enoxaparin, Jennifer learned that if I ordered it from Express Scripts, it would be $80 per month. I was very happy to hear that. It's double what I had been paying, but still a lot better than $200. But Thursday morning she called with bad news: the price is $200 after all. She got permission from senior Highmark administrators to do an over-ride so that I could re-fill it at CVS for $41 for one month only. When she mentioned that Highmark might want me to try a different (cheaper) blood thinner, I told her absolutely not. I've already been hospitalized three times with life-threatening pulmonary embolisms and I've had two blood thinners fail. This dosage of enoxaparin is working. I am NOT experimenting with any other blood thinner medications.

But wait, there's more! When I tried to refill the enoxaparin prescription at CVS, I received a message saying that I couldn't re-fill it until February 8! At this point, I had about a week of medication left. Missing even one dose means risking another blood clot or pulmonary embolism. I called Jennifer again; she found out that this problem occurred because my prescription was already in process at Accredo and you can't have two active prescriptions for the same medication. So she made arrangements to reduce the $200 charge at Accredo to $41, too. I'll pick up a 30-day prescription from CVS tomorrow and receive another month's supply from Accredo. However, this is just a short-term solution. Jennifer is still working on a long-term plan to reduce the cost. I greatly appreciate her concern for me. Still, I wish I didn't have this prescription cost problem in the first place.

My enoxaparin situation prompted Jenn Baka to email a PSU faculty listserv asking whether others are having difficulty with the switch to Highmark. I'm not the only one. Here is what Jenn reported back:

"Based on the 50+ emails I’ve received so far, I am seeing patterns that I wanted to share. The replies I have received have been mainly negative and revolve around four main concerns:

Prescriptions no longer covered (over 20 instances)

Significant price increases in prescriptions (10 instances)

Medical devices no longer covered/significant price increases (2 instances)

Communication concerns/challenges in dealing with Highmark—> concerns about receiving new insurance cards on December 24, getting conflicting info about whether prescriptions would be covered and/or costs (5 instances)

In terms of prescriptions, it seems the main medicines of concern have been thyroid medicine (Synthroid no longer covered), blood thinners (Enoxaparin price increases of over 2000%) and epinephrine pens (Auvi-Q no longer covered). 

Please reach out to benefits@psu.edu for help with your specific needs. HR does not know who specifically received letters due to privacy rules. I have received positive feedback from some of you about the responsiveness of HR. The head of HR, Jennifer Wilkes, has also gotten personally involved in some cases."

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If any of you are having trouble with Highmark coverage for prescriptions or medical care, do contact PSU Benefits and also let Jenn Baka know so that she can document this for the Faculty Benefits Committee (who, by the way, was not consulted at all about the switch to Highmark). Senior PSU administrators aren't even trying to pretend that they care about shared governance. The plan to switch to Highmark was in the works for 6 months and no one said a word about it to Faculty Benefits.

When I discussed this situation with a local doctor, he explained that this is all about preventing UPMC (University of Pittsburgh Medical Center) from continuing its eastward expansion, while also limiting the growth of U Penn's healthcare system. He said Highmark gave $1 billion to Penn State Health so that they could build several new hospitals and expand healthcare in PA. (It turns out they signed a $1 billion deal; it wasn't exactly a donation.) He thinks that without this, Penn State Hershey would have gone under and we would have only two main healthcare providers in PA, which would not be a good situation. But in light of this deal, it comes as no surprise that Penn State would switch to Highmark insurance. It seems that PSU will save $20 million (reportedly) in part by refusing to cover or charging more for medications that some of us need to stay alive.