Today i was declined refill on my pulmozyme????!

[JustDucky]

Hi Carly, yeah, first check to see if the prescription itself has not expired. If it hasn't , since you have parts A and B medicare, you should still be covered for pulmozyme. I have medicare as my primary for A and B as well as part D for my prescriptions. Now, since pulmozyme has to be nebulized, it is covered under part B medicare, you just have a 20% out of pocket expense which should be picked up by one of your other insurances (Cigna or medicaid). I have been on pulmozyme since my dx in 2005 and medicare has picked it up no problem, my medigap insurance has always picked up the remaining 20% tab that medicare does not cover. The same goes with any nebbed med that is on the formulary such as atrovent, albuterol, hypertonic saline, TOBI, pulmocort. The ones that aren't covered under part B are Colistin and Cayston (too early, it will probably be added on the formulary within a few years hopefully, Colistin isn't because it isn't FDA approved to be nebbed for PA...at least that was the explanation that was given to me). Good luck, you should have coverage one way or another...you may have to go through a pharmacy that processes medicare, many retail drug stores do not, so it is usually somewhere like Foundation care (which by the way, rocks!) or Curascript (which I do not like...it took forever to get my meds straightened out when I used them).
<br />
<br />Jenn

 

[carly23]

Hey yall thanks for the responses ok..update so i talkt o all three of my insurances and there sayin because i have cigna thats what i have to use?????so confused because all my other medicenes are ok with medicare part d?and then i was able to same day refill my hypertonic saline no problems?my pulmozyme is not expired or needing new refills what not.so now with this being an issue im on like 595$ a month disability and i can no way afford 50-100$ copays!i have bills to just like everyone else how do they expect me to pay that!?im worried i almost want to just say dang if this is such a big burden i wont do the dang medicene!but i know thats not the answer there has to be an answer out there!im not sure im not the only one!but how can this one be so complicated all of a sudden!? when i did my cayston last month i got two aproval letters from cigna and medicare the lady at that office told me we could go with medicare as that was only a 3$ copay!versus cigna and a 50$ copay!so yea of course i went with medicare but see what im not understanding to is how my social worker s saying ican get in alot of trouble not just using my cigna i mean i have medicare and if its that cheap with my income it works perfect i cant and will never be able to afford high dollar copays on my fixed income!so frustrating <img src="i/expressions/face-icon-small-sad.gif" border="0"> im still not sure what to do today is my last dose i have and then im out i do see my cf doc tuesday though

 

[carly23]

Hey yall thanks for the responses ok..update so i talkt o all three of my insurances and there sayin because i have cigna thats what i have to use?????so confused because all my other medicenes are ok with medicare part d?and then i was able to same day refill my hypertonic saline no problems?my pulmozyme is not expired or needing new refills what not.so now with this being an issue im on like 595$ a month disability and i can no way afford 50-100$ copays!i have bills to just like everyone else how do they expect me to pay that!?im worried i almost want to just say dang if this is such a big burden i wont do the dang medicene!but i know thats not the answer there has to be an answer out there!im not sure im not the only one!but how can this one be so complicated all of a sudden!? when i did my cayston last month i got two aproval letters from cigna and medicare the lady at that office told me we could go with medicare as that was only a 3$ copay!versus cigna and a 50$ copay!so yea of course i went with medicare but see what im not understanding to is how my social worker s saying ican get in alot of trouble not just using my cigna i mean i have medicare and if its that cheap with my income it works perfect i cant and will never be able to afford high dollar copays on my fixed income!so frustrating <img src="i/expressions/face-icon-small-sad.gif" border="0"> im still not sure what to do today is my last dose i have and then im out i do see my cf doc tuesday though

 

[carly23]

Hey yall thanks for the responses ok..update so i talkt o all three of my insurances and there sayin because i have cigna thats what i have to use?????so confused because all my other medicenes are ok with medicare part d?and then i was able to same day refill my hypertonic saline no problems?my pulmozyme is not expired or needing new refills what not.so now with this being an issue im on like 595$ a month disability and i can no way afford 50-100$ copays!i have bills to just like everyone else how do they expect me to pay that!?im worried i almost want to just say dang if this is such a big burden i wont do the dang medicene!but i know thats not the answer there has to be an answer out there!im not sure im not the only one!but how can this one be so complicated all of a sudden!? when i did my cayston last month i got two aproval letters from cigna and medicare the lady at that office told me we could go with medicare as that was only a 3$ copay!versus cigna and a 50$ copay!so yea of course i went with medicare but see what im not understanding to is how my social worker s saying ican get in alot of trouble not just using my cigna i mean i have medicare and if its that cheap with my income it works perfect i cant and will never be able to afford high dollar copays on my fixed income!so frustrating <img src="i/expressions/face-icon-small-sad.gif" border="0"> im still not sure what to do today is my last dose i have and then im out i do see my cf doc tuesday though

 

[Giggles]

Sorry you are having troubles what a pain. Sounds like Cigna might be your primary insurance and Medicare is secondary. If that is the case you do have to go through Cigna and then have the pharmacy submit first to them and then to Medicare and it should be covered with no out of pocket. BUT you have to use a pharmacy that will submit to Medicare as secondary and typically when using the mailorder plan with primary Cigna you have to find out if that mail order pharmacy WILL submit to Medicare secondary sometimes they won't and we are SOL....Which goes to show how screwed up insurance is cause you are paying for Medicare and can not use it. What makes it difficult is Pulmozyme is a specialty drug at least that is what Primary plans like Cigna or whatever call it and since it is specialty you HAVE to order from primary plans mail order pharmacy and then if they will not bill medicare than we are just out of luck it sucks. Not sure if what I described is your scenario but couuld be and it is how it works for me.... Foundation Care Pharmacy if you can get the Pulmozyme from them will bill your primary Cigna and Secondary Medicare if that is the scenario for you and you can get pulmo not from Cigna mail order and their number is 1-877-291-1122. Otherwise, make sure RX is not expired and that is why they will not refill it. They only are good for one year and then it is denied but only cause you need a new RX which is a an easy fix. Then find out about who is primary and if Medicare is Secondary or what..... If you are on a group plan like Cigna and the employer has over 100 employees then Cigna is primary. If under 100 employees then your Medicare is Primary. Good Luck. Nothing like jumping through hoops, story of a CF'rs life with insurance. It is like a necessary evil. Good luck!

Jennifer 38 with Cf and CFRD

 

[Giggles]

Sorry you are having troubles what a pain. Sounds like Cigna might be your primary insurance and Medicare is secondary. If that is the case you do have to go through Cigna and then have the pharmacy submit first to them and then to Medicare and it should be covered with no out of pocket. BUT you have to use a pharmacy that will submit to Medicare as secondary and typically when using the mailorder plan with primary Cigna you have to find out if that mail order pharmacy WILL submit to Medicare secondary sometimes they won't and we are SOL....Which goes to show how screwed up insurance is cause you are paying for Medicare and can not use it. What makes it difficult is Pulmozyme is a specialty drug at least that is what Primary plans like Cigna or whatever call it and since it is specialty you HAVE to order from primary plans mail order pharmacy and then if they will not bill medicare than we are just out of luck it sucks. Not sure if what I described is your scenario but couuld be and it is how it works for me.... Foundation Care Pharmacy if you can get the Pulmozyme from them will bill your primary Cigna and Secondary Medicare if that is the scenario for you and you can get pulmo not from Cigna mail order and their number is 1-877-291-1122. Otherwise, make sure RX is not expired and that is why they will not refill it. They only are good for one year and then it is denied but only cause you need a new RX which is a an easy fix. Then find out about who is primary and if Medicare is Secondary or what..... If you are on a group plan like Cigna and the employer has over 100 employees then Cigna is primary. If under 100 employees then your Medicare is Primary. Good Luck. Nothing like jumping through hoops, story of a CF'rs life with insurance. It is like a necessary evil. Good luck!

Jennifer 38 with Cf and CFRD

 

[Giggles]

Sorry you are having troubles what a pain. Sounds like Cigna might be your primary insurance and Medicare is secondary. If that is the case you do have to go through Cigna and then have the pharmacy submit first to them and then to Medicare and it should be covered with no out of pocket. BUT you have to use a pharmacy that will submit to Medicare as secondary and typically when using the mailorder plan with primary Cigna you have to find out if that mail order pharmacy WILL submit to Medicare secondary sometimes they won't and we are SOL....Which goes to show how screwed up insurance is cause you are paying for Medicare and can not use it. What makes it difficult is Pulmozyme is a specialty drug at least that is what Primary plans like Cigna or whatever call it and since it is specialty you HAVE to order from primary plans mail order pharmacy and then if they will not bill medicare than we are just out of luck it sucks. Not sure if what I described is your scenario but couuld be and it is how it works for me.... Foundation Care Pharmacy if you can get the Pulmozyme from them will bill your primary Cigna and Secondary Medicare if that is the scenario for you and you can get pulmo not from Cigna mail order and their number is 1-877-291-1122. Otherwise, make sure RX is not expired and that is why they will not refill it. They only are good for one year and then it is denied but only cause you need a new RX which is a an easy fix. Then find out about who is primary and if Medicare is Secondary or what..... If you are on a group plan like Cigna and the employer has over 100 employees then Cigna is primary. If under 100 employees then your Medicare is Primary. Good Luck. Nothing like jumping through hoops, story of a CF'rs life with insurance. It is like a necessary evil. Good luck!
<br />
<br />Jennifer 38 with Cf and CFRD

 

[carly23]

Hey giggles thank you that was really helpful!now the only thing im still not getting though is this pharmacy iv been using for years and like my creon and inhalers anxiety meds hypertonic saline is all being apporved by medicare and the pharmacy lets me use medicare and uses cigna last i believe??..this has never been an issue till the other day and it does suck bad!i mean i guess my other thinking is if it wont at all be picked up my medicare then how am i going to pay for it im on 705 a month for disability!i cant pay for it so what would i do then??<img src="i/expressions/face-icon-small-sad.gif" border="0">

 

[carly23]

Hey giggles thank you that was really helpful!now the only thing im still not getting though is this pharmacy iv been using for years and like my creon and inhalers anxiety meds hypertonic saline is all being apporved by medicare and the pharmacy lets me use medicare and uses cigna last i believe??..this has never been an issue till the other day and it does suck bad!i mean i guess my other thinking is if it wont at all be picked up my medicare then how am i going to pay for it im on 705 a month for disability!i cant pay for it so what would i do then??<img src="i/expressions/face-icon-small-sad.gif" border="0">

 

[carly23]

Hey giggles thank you that was really helpful!now the only thing im still not getting though is this pharmacy iv been using for years and like my creon and inhalers anxiety meds hypertonic saline is all being apporved by medicare and the pharmacy lets me use medicare and uses cigna last i believe??..this has never been an issue till the other day and it does suck bad!i mean i guess my other thinking is if it wont at all be picked up my medicare then how am i going to pay for it im on 705 a month for disability!i cant pay for it so what would i do then??<img src="i/expressions/face-icon-small-sad.gif" border="0">

 

[carly23]

I also want to ask would it make sense to drop my dads insurance??then what will they do theyd have to use my medicare or would that be a big mistake?

 

[carly23]

I also want to ask would it make sense to drop my dads insurance??then what will they do theyd have to use my medicare or would that be a big mistake?

 

[carly23]

I also want to ask would it make sense to drop my dads insurance??then what will they do theyd have to use my medicare or would that be a big mistake?