Tobi Program -- Statement of benefits "error"

R

Ratatosk

Administrator
Staff member
So last summer the drug company handling Tobi announces that they're only going to sell to specific pharmacies to save costs, make life easier for us, cut out the middleman.... Since we've had to go thru a mail order pharmacy it's been stressful and according to our insurance statement of benefits, the cost has gone up from $6200 to $6995 for a 28 day dose -- I saw on the CF pharmacy price list they charge $8000.

First I had issues getting the prescription filled with the mail order pharmacy, which ironically is the same company providing our prescription insurance plan. There was a delay getting the script filled because supposedly the doctor only signed the form once instead of twice, yet nobody bothered to contact their office or us -- DS' first dose was delayed by a couple days. The drug company assured me next time, they'd call a week before we were due to fill the script to remind me to order.

Next order I get a call indicating they're going to fill the script, I just need to call back to confirm and despite our plan not requiring prior approval -- they can't send until they hear from our insurance company. Go round and round, get the script.


Next time I call a week in advance wanting to make sure they ship to my office instead of home because or subzero F temps. Every day I call to check on status, every day for a week, they say they can't do anything until they hear from my insurance company that it's covered. DS misses his first dose AGAIN. Wow, the three times I've ordered so far are soooooo easy and stress free -- NOT!

So this weekend I look at a statement of benefits for DS script's as DH is sending in all his flex stuff and I see that the prescription drug company charged our insurance company TWICE in November for Tobi -- the month DS was OFF. They sent in a charge for almost $7000 the beginning of the month and again the end of the month. Didn't charge the $15 copay on my credit cards that the did for August, October or December. Nor did they ship us the drug or contact us. Craziness!
 
R

Ratatosk

Administrator
Staff member
No, the Tobi program chose the pharmacy we're to deal with -- it's Prime Therapeutics out of Florida, which is kinda ironic because Prime Therapeutics is also where we get our prescription insurance on behalf of BCBS. I googled Prime and came up with all kinds of complaints to the BBB regarding them -- improper billing, filling scripts without authorization... I'm sure they have a perfectly reasonable explanation for sending in an almost $14,000 claim to bcbs. :)
 
R

Ratatosk

Administrator
Staff member
So we found out there's now a generic available from Teva and our local pharmacist has tried to fill the prescription and he's told it's too soon to order. Unfortunately, despite contacting the BCBS fraud department the mail order pharmacy has continued to submit charges at now $8000 a pop --- twice in January and so far once this month. I last ordered December 11th and they finally filled the script on December 16th. DH spent most of the afternoon on the phone with BCBS, who is still "investigating". Fortunately I have enough Tobi stocked up til we need it when ds is back on it next month, but am soooo frustrated with the whole situation.
 
R

Ratatosk

Administrator
Staff member
An update --- Yesterday our pharmacist attempted to order generic tobi for us.... He called to say our insurance company considered it a specialty drug and we'd need to pay $1000. Yikes. Meanwhile, we found there's another drug company -- Bethkis that makes a form of tobi, but it's considered non-formulary so we'd have to cough up half the cost, plus a $15 copay, which would be about $2500 a pop. Meanwhile our insurance company and the mail order pharmacy are calling the twice monthly submitted charges for a drug we neither ordered or received a "glitch" -- a $14,000 glitch that has caused ds to NOT be able to fill his script. Oh and then the mail order company proceeded to once again charge BCBS for Tobi. BCBS was able to reverse those charges, we're trying to arrange it so we never have to deal with said mail order pharmacy again and order from our local pharmacist. In the midst of all this, too we found our insurance coverage was changed by HR, who promised no changes.... Instead of $1000 of pocket maximum with $15-30 copays after reaching that amount -- we now have $4500 for all medical related charges and then zero copay unless we'd order a noncovered, non formulary drug or procedure. Yikes, I would've flexed some extra $$$ if I'd known. That seemed daunting at first, but then I realized it may all work out because once we reach that amount --- our cost for the year is 0 and a lot of times, I've spent my $2000 in flex before summer and then get nickled and dimed in copays!
 
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