question about children with growth hormone deficency and insurance

[robertsmom]

My DS(9) has been taking Norditropin for growth hormone deficency for about 2 years and it has made SUCH a difference. He has grown six inches in 2 years. His growth all but stopped at 4 (between 4 and 7 he only grew 4 inches) and with Noditropin he has almost tripled his growth rate. My problem is up till now he has been on government insurance which paid the whole cost of his prescription, but now I make too much money to qualify so I have to put him on my work insurance. I am wondering if anyone with kids on growth hormone meds can tell me what portion insurance will pay for. My biggest fear is that I won't be able to afford these meds for him anymore (right now he uses three vials a month at 750 per vial and the price will increase whenever he needs a larger dosage). My insurance is Blue Cross/Blue Shield if that makes a difference. Thanks for any help!

 

[Cheshire Figment]

My insurance is Blue Cross/Blue Shield if that makes a difference.

I have BC/BS from the Federal Employee program. First I would suggest you read the book that you should have gotten at the beginning of the year. If you do not have the book either go to your HR office or call the customer service number on the back of your BCBS card. Under my program I must use the mail order system for all recurring prescriptions and I have copays of either $10 (generic) or $35 (non-generic) per prescription or refill and each prescription or refill can cover up to 90 days medication. I know on one of my medications their share on a 90 day supply is about $4,000 while I only have to pay $35 out of pocket.

 

[KPeterso]

I have worked in specialty pharmacy for several years. I did growth hormone benefits several years ago for awhile. It really all depends on the insurance how they want to cover it. I can tell you it will require what your insurance will call a prior authorization (about 95% of insurances require it for gh). Make sure to call your insurance company right away to see what information is required and where your MD can submit it to get approved. Depending on the insurance, it can take anywhere from 1-2 days up to 30 days, so make sure you get a good supply on hand before switching the insurance. Also make sure to alert your pharmacy (I assume it will be a specialty one that sends it to your home) as soon as you change. Do NOT wait until you need an order because by then it will be too late (that is from personal experience and was always one of my biggest pet peeves). If your current pharmacy is out of network and you do not tell them in advance, you will go without or be asked to pay for any sent without an auth. I hate to say it, but most gh falls under major medical benefits. Check with the manufacturer (there should be a manufacturer program, but I can't remember who Norditropin is through)or the Magic Foundation to see if you can apply for copay assistance if you cannot afford it. This should give you a good start, but if you have any questuons, let me know.