epi/insurance questions

Posted on: Sun, 11/12/2006 - 9:53pm
melissa's picture
Joined: 07/05/2004 - 09:00

We have new insurance that requires maintenance medications to be filled via mail order. Just found out the hard way they consider epi maintenance. We just refilled DS's epi a few weeks ago and this weekend DH left it on the dash in his car and it was over 90 degrees inside. Pharmacist said we should refill it...which he did and when we picked it up it was $137!!! He said the insurance wouldn't pay for it b/c we were only allowed one local fill per medication.
Our insurance is through Anthem but our Rx coverage is Caremark. I called and got a nice customer service rep who said she couldn't help me.
My questions are:
1. Those of you who have similar policies, what happens if you have to use an epi, or you lose one? Do you wait 10-14 days for mail order or suck it up and pay the big bucks.
2. Do you worry that when they mail your epi it will sit in your mailbox for several hours in the heat or cold?
3. How do I get to someone in decision making authority at Caremark who might be willing to listen to my concerns?
4. Am I making too big a deal out of this or is this worthwhile to tackle? We have 4 epi rx's in various places and I need to figure out the best plan of attack for having them filled.

Posted on: Sun, 11/12/2006 - 10:59pm
saknjmom's picture
Joined: 04/02/2003 - 09:00

Quite honestly, I hate mail order pharmacies. There are some things we are supposed to do through mail like vitamins for DS etc. I just pay the extra.
Epi pens are not maintenance in my opinion. They are not used every day like Singular or something you take everyday. Maintenance means ongoing care, right?
I would keep fighting. You should be able to refill that script immediately considering the consequences of not having a current epi pen.
Even though you ruined it, you should be able to get one right away. I'd fight this one!
Look at the information for your plan and see if you can decifer the fine print.

Posted on: Sun, 11/12/2006 - 11:04pm
saknjmom's picture
Joined: 04/02/2003 - 09:00

This is Caremark's definition from their website. Link below.
What is a maintenance medicine?
A maintenance medicine is one that must be taken on a regular basis for chronic conditions. You can save money on these medicines by using your Caremark Mail Service pharmacy benefit. To make full use of the Caremark Mail Service program, ask your doctor to write one prescription for up to a 30-day supply for immediate needs for your short-term medicine to be filled at your local retail pharmacy and a second prescription for your mail service program with up to a 90-day supply of medicine along with the appropriate number of refills (normally three refills, which is a year

Posted on: Mon, 11/13/2006 - 12:34am
krc's picture
Joined: 01/16/2007 - 09:00

Our doctor writes the script for a 90 day supply, Quantity 6. So we receive 6 at a time for one copay. I was amazed at this!
Have you called to see what your maximum allowed is? We also have Anthem and can fill an rx once at a local pharmacy and then it costs double (or more) to fill locally again so we have to use mail order also. But we fill the first rx for the Epi's at the local pharm and since we receive so many, we're covered until the next year.

Posted on: Mon, 11/13/2006 - 2:14am
Momcat's picture
Joined: 03/15/2005 - 09:00

We have a mail order pharmacy, but epipens are not considered maintainence meds. We get the epis at the local pharmacy.

Posted on: Mon, 11/13/2006 - 5:57am
SallyL's picture
Joined: 02/20/2006 - 09:00

I don't think they should expect you to get Epipens thorugh the mail!! You never know what kind of heat or cold they are exposed to, and whether or not they've been comprised through rough handling or something.
I don't know how your insurance works, I've never heard of this before, but I think you'd have a good argument for getting them locally. Could your doctor maybe write you a note to pass on? Surely the allergist would agree?

Posted on: Mon, 11/13/2006 - 6:05am
Corvallis Mom's picture
Joined: 05/22/2001 - 09:00

I've a suggestion for you-- contact DEY directly.
Ask them what they think of mail-order shipping of epinephrine autoinjectors. (I am assuming that these are not coming overnight in styrofoam packaging, just standard ground frieght, right?)
My guess is that Dey will have some choice things to say about the practice.
So contact them via e-mail and ask permission to forward their reply to your HMO.

Posted on: Mon, 11/13/2006 - 6:23am
Going Nuts's picture
Joined: 10/04/2001 - 09:00

I would ask for help from both your MD and Dey, and I would continue to fight.
One thing I learned when we had Blue Cross/Blue Shield was that they automatically denied anything that was slightly out of the ordinary. Their assumption is that a certain percentage of people will just give up and pay themselves. However, they ended up paying everything I disputed (they just drove me crazy in the process!).
I also would not accept epi through the mail. I don't know where you live, but epi is something that can't be exposed to temp extremes (I guess that's how you wound up here in the first place [img]http://uumor.pair.com/nutalle2/peanutallergy/wink.gif[/img] ), so it can't sit in a mailbox all day. Absolutely ridiculous! It's also something you can't be without during the time it takes to mail it.
Have your MD and/or Dey confirm the above info, and fight, fight, fight.

Posted on: Mon, 11/13/2006 - 11:06am
melissa's picture
Joined: 07/05/2004 - 09:00

Well, the plot thickens.
Thanks to all the suggestions above, I called Dey and they said epi should never be considered a maintenance med, they had a problem w/ it being shipped in that manner (being exposed to weather extremes) and gave me a # for Caremark to call them for more info; they too suggested I call our dr for help w/ this.
I decided to call Caremark back. I got another customer svc rep who wanted to get rid of me but just couldn't. He ended up putting me on hold 3 times while he talked to his supervisor. He finally came back and told me that epi is not considered a maintenance drug w/ Caremark and the Rx should not have been denied. So why was it? I will go to the Kroger pharmacy tomorrow and see what the reasoning is. Caremark rep said the only thing he could guess is that since I had just recently filled the rx, that it was denied b/c it is too soon to get another one, but he said if that's the case, the local pharmacist should have called Caremark for an override...we could have explained what happened and they would have, most likely, filled it again for our copay.
So, we'll see who's right and what happens next.
Thanks again for all the great suggestions!

Posted on: Wed, 11/15/2006 - 1:22am
solarflare's picture
Joined: 02/07/2002 - 09:00

It sounded strange to me. We've had Caremark for a few years now since they bought out AdvancePCS, and we've always been able to refill our epis at the pharmacy of our choice.
Cheryl, mom to Jason (9 MFA including peanuts, tree nuts, shellfish and egg)
Joey (7 NKA)
Allison (3 MFA including milk, butternut squash, several fruits and suspected shellfish allergies, avoiding tree nuts, RAST - for peanut)
Ryan (born 12/27/05) nka *knock on wood*

Posted on: Wed, 11/15/2006 - 2:55am
melissa's picture
Joined: 07/05/2004 - 09:00

New day, different answers again.
Now I find out that epi is not considered maintenance BUT our plan says that ALL medications (other than antibiotics and the like) can be filled 1x at our local pharmacy w/ 1 refill and then after that, forever, it must be mail order. The very nice person at Caremark (3rd very nice person I've talked to there, I have to credit their customer service skills) said this is not a battle w/ them, it is w/ our company insurance administrator. My husband has only been at this job since August so I hope this doesn't mess his "status" up, but we're going to have to plead our case w/ them to get this policy changed. Either that or cough up $137 each time w/ need an epi. If it ends up not being changed, I wonder if we got one Rx for 4 sets of epi-jr 2packs if we could get away w/ only paying $137 one time a year (barring of course we don't lose one, use one, or ruin one, in which case we'll have to pay it again) or since it is not under insurance would we have to pay $137 x4?
So frustrating...


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