TLDR: I have a new Anthem California HMO insurance plan. For three weeks they have been saying they will be sending out my Cosentyx but haven't. Any suggestions on what to do?
The Background: I recently moved states (back home to CA) so I had to change insurance. I have always had PPO's but I'm self-employed so the plans are limited and expensive and $800/month for the cheapest PPO isn't feasible so I went with a "silver" level HMO (for the low, low price of about $400/month).
I knew I would need a referral from a GP to see a specialist (and that whole chain would take 2-3 months at least) so I had my old rheumatologist send the prescription to the specialty pharmacy for the new insurance (Anthem CA's mail order/speciality pharmacy is thru Carelon. I thought Express Scripts was bad but Carelon makes Express Scripts seem amazing!). Gave Carelon the copay assistance info, they say "great, looks good, we should be able to send this out tomorrow or the next day." (I foolishly think, "Wow, that was way easier than I thought. Look at me being on top of things!")
When it doesn't arrive, I call and they say, "oh well you need a prior auth." I say, "Okay, um, were you going to mention that at any point? Maybe could have said something last week but okay..."
Doc sends in the prior auth and the Carelon pharmacy says "great, looks good, we should be sending it out in the next few days." Then doctors office lets me know it's been rejected but that no reason was given and they've asked but aren't hearing back. Fast forward thru several hours of phone calls, a half dozen reps later, and no clear explanation on why it was been rejected but just that the doctor's office should supposed to call back and provide either more information, a different diagnosis, or about 3-4 other possibilities (I got a different answer from each person I spoke with).
The doctor's office has called back to do the prior auth by phone but I'm again stuck waiting for insurance to approve or deny it and I'm just at my whits end with them. I've left out a bunch of maddening details like the fact that insurance still has not notified me that the prior auth was denied (I only found out bc the doctor's office let me know - isn't that a requirement???).
It's super important to not skip doses and I'm starting to have a flare up (my last dose had made the 3 day drive with me back to CA and even though I did my best to keep it refrigerated, I think it was probably a bit compromised). Is there anything I can do (other than checking in with insurance daily? Am I just at their mercy?
I'm going to call Cosentyx's patient assistance program in the morning and see if I can beg them to send me a dose or to cover the cost for the insurance to send one but I don't think that's an option bc they're not a pharmacy and I don't think it works that way. Arg! Any ideas? Has anyone else been in a similar situation?
