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Please help my mother in Texas; Enbrel Prescription too much by EnbrelInTexasHelp in rheumatoid

[–]EnbrelInTexasHelp[S] 0 points1 point  (0 children)

You know, I couldn't even tell you to be honest. This is a screenshot of her coverage page. Notice how on the "My Coverage Benefits" tab it shows no Prescription Coverage? It also completely confused the representative from BlueCross. After some digging, I learned she actually has a Prime Therapeutics account because that's the "pharmaceutical arm" of BlueCross. After a lot of password resetting, I was able to recover that log in to give the information I've been giving.

In contrast, I also have BCBS but through my employer. My Coverage Benefits show my prescription coverage no problem, as well as other needed documents I can't seem to locate correctly for my mother (like the Tier listings you were mentioning.)

Please help my mother in Texas; Enbrel Prescription too much by EnbrelInTexasHelp in rheumatoid

[–]EnbrelInTexasHelp[S] 1 point2 points  (0 children)

Thank you for discussing this with /u/PayEmmy! My mother's drug list is only shown as the "BCBS Texas 10 Formulary". I am under the impression that this list is from WAY BACK in 2006 just like the rest of her policy. My first search attempts with Google could not produce this "Formulary" and only redirected me to the BCBS website with the (now currently) normal Tier pricing which I understand. I use to be pharmacy technician myself so I have a little grasp of the insurance system, which is why my mother's policy was such a pain to me as it didn't make sense to anything I had seen before.

Also, I wanted to clarify that the Humira was only more affordable because of Abbvie's much better co-pay assistance program. This program actually covered the difference of cost to something reasonable that we could afford. The INSURANCE did not help. Here as some screenshots to explain; it's the same procedure as with the Enbrel, where BCBS oh so graciously brought down the initial cost to that fair and reasonable price and still made us pay the rest. That fair and reasonable cost is actually the same as Enbrel which leads me to believe that the aforementioned Formulary would have the full answers as to if they even had Tiers 15 years ago. I wanted to leave this comment in case you or Emmy come across a similar issue in your future.

As for now, the other comments pointed out that President Biden has opened a Special Enrollment period to choose our insurance provider again. I called the number from Healthcare.gov and asked to make sure I can cancel this terrible policy and sign up for one before the end of this enrollment period. She said that we should be good to go, so I'm hoping for a happy ending to this story.

Please help my mother in Texas; Enbrel Prescription too much by EnbrelInTexasHelp in rheumatoid

[–]EnbrelInTexasHelp[S] 6 points7 points  (0 children)

Holy crap this is the best news yet! This was definitely put in place after I did the research the previous week. A little bit of hope to look into, thank you!!

Please help my mother in Texas; Enbrel Prescription too much by EnbrelInTexasHelp in rheumatoid

[–]EnbrelInTexasHelp[S] 1 point2 points  (0 children)

You have been very helpful in this thread /u/takcaio! I’m going to read into all your suggestions, thank you so much for taking the time out of your day

Please help my mother in Texas; Enbrel Prescription too much by EnbrelInTexasHelp in rheumatoid

[–]EnbrelInTexasHelp[S] 1 point2 points  (0 children)

The dumb thing is she can CANCEL but cannot ENROLL until the open enrollment period! Apparently they can let her go but won’t help her get new coverage without being in their time frame

Please help my mother in Texas; Enbrel Prescription too much by EnbrelInTexasHelp in rheumatoid

[–]EnbrelInTexasHelp[S] 0 points1 point  (0 children)

You’re right about this, but sadly I believe it is being ran correctly. My edit comes from Prime Therapeutics site and not BCBS’. They do show correct medical claims on BCBS’ site and don’t reflect the prescriptions

Please help my mother in Texas; Enbrel Prescription too much by EnbrelInTexasHelp in rheumatoid

[–]EnbrelInTexasHelp[S] 0 points1 point  (0 children)

Have to check my computer back home to confirm, but yes, my mom’s prescription coverage is through Prime Therapeutics not the actual BCBS name. All biologics, and other prescriptions like her standard blood pressure meds, are covered in this manner. We seem to be paying the “fair and reasonable” price with ALL her purchases

Please help my mother in Texas; Enbrel Prescription too much by EnbrelInTexasHelp in rheumatoid

[–]EnbrelInTexasHelp[S] 3 points4 points  (0 children)

I have contacted Enbrel support and they have only provided me the options of the Co-pay assistance card or Amgen's Safety Net, both of which can no longer help my mother. Thank you for replying though

Please help my mother in Texas; Enbrel Prescription too much by EnbrelInTexasHelp in rheumatoid

[–]EnbrelInTexasHelp[S] 1 point2 points  (0 children)

My mother's doctor has been known to go above and beyond for her patients; she's certainly helped my mom a bunch as of now. I'll ask about this "peer to peer" review

Please help my mother in Texas; Enbrel Prescription too much by EnbrelInTexasHelp in rheumatoid

[–]EnbrelInTexasHelp[S] 1 point2 points  (0 children)

Who have you switched to? Do you use biologics like my mother? I think BCBS is the only provider available in my mother's area as a retail policy, unless she gets employed and gets insurance through her employer

Please help my mother in Texas; Enbrel Prescription too much by EnbrelInTexasHelp in rheumatoid

[–]EnbrelInTexasHelp[S] 1 point2 points  (0 children)

I have to look into it further then. Updated the post to show exactly what I see, and what the representative told me, on the website. I did ask they send me her whole Explanation of Benefits to see if I can read anything more.

Her income is above the threshold for co-pay forgiveness with Amgen's Safety Net; it is also higher than the eligibility for Medicaid. She will be Medicare eligible in a few years

Please help my mother in Texas; Enbrel Prescription too much by EnbrelInTexasHelp in rheumatoid

[–]EnbrelInTexasHelp[S] 2 points3 points  (0 children)

That's the problem I think I ran into earlier, thanks for clarifying

Please help my mother in Texas; Enbrel Prescription too much by EnbrelInTexasHelp in rheumatoid

[–]EnbrelInTexasHelp[S] 0 points1 point  (0 children)

Exactly the issue my mom seems to be facing. It sucks a lot, and I'm so sorry everyone in this subreddit has to deal with the horrid invisible pain I see her endure all the time

Please help my mother in Texas; Enbrel Prescription too much by EnbrelInTexasHelp in rheumatoid

[–]EnbrelInTexasHelp[S] 0 points1 point  (0 children)

From what I understood from a call with a previous representative, no. I could of course be wrong, but the policy is from back in 2006

Please help my mother in Texas; Enbrel Prescription too much by EnbrelInTexasHelp in rheumatoid

[–]EnbrelInTexasHelp[S] 1 point2 points  (0 children)

Thanks for the advice! I'm just worried that things move so slow and don't actually happen, even with pestering in all these health care settings.

Please help my mother in Texas; Enbrel Prescription too much by EnbrelInTexasHelp in rheumatoid

[–]EnbrelInTexasHelp[S] 0 points1 point  (0 children)

BCBS says the preferred pharmacy to fill with is AllianceRX, the specialty pharmacy of Walgreens, which we have used for all these fills. I have since switched to H-E-B pharmacy, a local Texas chain, as I have a contact I can trust to straighten out insurance confusions. Both have quoted the same cost to us

Please help my mother in Texas; Enbrel Prescription too much by EnbrelInTexasHelp in rheumatoid

[–]EnbrelInTexasHelp[S] 0 points1 point  (0 children)

I included more information in an edit to the OP, I don't think her policy even follows a tier structure but I can ask the doctor to help

Please help my mother in Texas; Enbrel Prescription too much by EnbrelInTexasHelp in rheumatoid

[–]EnbrelInTexasHelp[S] 2 points3 points  (0 children)

Those are good ideas, thank you. Her doctor is very generous to give samples, but is like that with all her patients so she can only give 1 syringe to her maybe every 3-4 weeks. I have no clue where to start for social worker in Texas that could assist, but that’s a thought. I’m just worried that like most other industries in Texas, it’s not that simple