RX payment question - Group Ins,Medicare & grant $

[HappyGilmore]

Hello,

My husband is a cancer survivor stage 4 lung cancer with brain mets. He is on a very expensive oral drug called Xalkori ($11,000+ per month). I have employer group coverage (primary) , he has medicare part D (secondary) and we qualified for a grant from Patient Access Network foundation. My employer group health plan changed Jan 2014 but prior to the change we only paid $60.00 copay which the grant paid so $0.00 out of pocket!!. The pharmacy we got the drug from in 2013 doesn't have the capability to file the claim through 2 insurances and in a few months will become an out of network pharmacy so I decided to move the rx to a in network pharmacy that can do coordination of benefits. With my new plan we pay 35% of the cost of the drug, then with medicare we pay currently 33% until gap then it goes to 45% then it will fall back down to 5%. I have been cutting through red tape for over a month trying to get this medication set up to be covered by my health plan then medicare and finally the grant. Yesterday I was told by the pharmacy that since we have medicare we can't use the grant (per medicare laws). Problem is I don't believe this is correct. I verified with the previous pharmacy as well as the organization that provided the grant AND medicare and all three told me that was incorrect. Has anyone had an experience with a similar situation like this with 3 payees for a rx claim? Can it be done? I just am wondering if the "grocery store pharmacy" that I am currently working with (in network on my insurance plan) just doesn't know how to process.

I feel as if I am having an anxiety attack that is lasting all month. My husband needs this medication to keep his cancer from spreading but the red tape is driving me CRAZY!

 

[malibuconlee]

No personal experience.

I guess I would try 2 things. First can you get in writing from the grant company AND Medicare that this is allowed? I would call and ask for that.

Is there a smaller locally owned pharmacy that is in-network? Maybe you would have better luck there trying to get someone to coordinate between all parties.

What a pain. Hope you are able to make some headway, good luck!!

 

[teacup princess]

Coupons and manufacturer discount cards are not allowed with any government program. I do not know about grants. These cards usually state on the back that they are excluded from being used with medicare and Medicaid. Flip the card over. Does it say that on the back? Are you allowed to submit a paper claim? That might be your only option if the pharmacy can't triple bill it.

 

[teacup princess]

https://www.panfoundation.org/fundingapplication/faq.php

If this is the patient assistant program you are referring to under FAQ it states the patient can submit a claim. It's a bit more of a hassle and you'll have to ay the insurance copay and then wait for reimbursement but it's an option.

 

[Straitlover]

Haven you checked into using a cancer drug specific pharmacy? My mother gets a cancer chemo drug (cost is around $8,800 per month), and it is paid for by her Medicare Part D and a private nonprofit grant. She uses Biologics Pharmacy based in Cary NC, who only deals w/ cancer medications. They send the medicine viz FedEx and bills her Part D and the grant.

Since they deal w/ this all the time, they may be better able to handle the triple billing. There are lots of other cancer pharmacies, but we have had great interaction w/ Biologics.

She can use the grant w/ her Part D because it's a nonprofit agency not run by the drug companies.

 

[sherreis]

Ask your Human Resources department who your Pharmacy Benefits Manager (PBM) is. A lot of the PBMs have specialty pharmacies which handle the more expensive medications, such as chemotherapy. I know that Express Scripts and Caremark both have specialty pharmacies. You can then ask for the contact information and see if they would be billing to file. They also deal via mail order and shipping vs. dealing with a local pharmacy.

Also, in case it helpful, your insurance might offer Case Management and a Case Manager might be able to assist you.

Good luck with dealing with this matter and most importantly, good luck with your husband!!!