Last year, Babygirl "graduated" from pediatric neurology to adult neurology. We met the adult neurologist, liked him, scheduled her for her Botox, three months in advance of when she needed to get the shots. Remember this story? (Cancelled.....) Two weeks before the appointment, they let us know that they wouldn't take our insurance for the Botox injections, leaving us SCRAMBLING to get her taken care of. Thankfully, pediatric neurology stepped up, and we were okay until her new insurance kicked in.
We tried, REALLY tried, to tie her neurology with her new kidney doctors in Rochester, but the group there is insistently NOT taking new patients, and the next nearest group is an hour farther away, almost to Buffalo. Too far, unless we want to start paying for hotel rooms (which, of course, we will if we must!).
So we started again with the local guy. I called ahead, told them specifically what type of insurance she now has. I called her insurance to make sure Botox is covered. When we were there on June 9th I made absolutely SURE that they had all of her cards, all of her data. I made a point of reminding them of what happened last time and asking politely, honest, that they work ahead of time to make sure it didn't happen again.
Today (!!!) their office called to let me know that they wouldn't be able to do her botox on September 4th because our insurance wouldn't cover it.
....W...T....
I listened while the same woman who told me this crap last time steamrollered over all attempts I made to speak up and finally just waited until she finished her rediculousness with "so she'll have to go back to where she's BEEN getting her shots or go and see Dr Khan at pain management." (Once again - the pain management group at the hospital I DON'T work at. The one our insurance doesn't cover, that used to cost hubby about $1000/visit until our hospital opened their own pain management office.)
Breathe.
So. "Do you actually know who I am?" Well, you are Babygirl's mother. "Yes, and I am also Dr D, so I know how authorizations work. Did you get authorization from her NEW insurance?" No. Your old insurance is her PRIMARY insurance. "I assure you it is not. All of her medications are being paid for by her new insurance. I told your office this when we scheduled the appointment. AND if they, for some reason, do not pay for this, I will, as I told you last time, PAY CASH."
I took a moment to explain to her that a 21 year old cannot "go back to" a pediatrician for any more shots, and unless she could guarantee me an appointment with Dr Khan by September 4th and the he would, indeed, take our insurance, then they were obligated to keep their committment to Babygirl.
I also took the low road and told her that I did not wish to have Babygirl's headaches relapse, and go back to a time when she did not find life worth living.
Her tone was less aggressive by the end of the conversation. She said she would discuss it with the doctor in the morning, and call me back tomorrow.
After I got home, I got a call from Babygirl's new insurance: Botox isn't covered. You can appeal by calling...
So we called. The customer service representative was polite, and told us that she had to try 2 preferred medications first. "Tell me what they are. I'm sure she's tried them."
Emagality, and Aimovig.
Well, CRAP. These drugs are relatively new, monthly self-injectables, immune modulators. Her last neurologist wanted her on Aimovig, but the kidney doctors, both pediatric AND adult, said NO. I'm a doctor, and I'm not sure what the objection is, exactly, but no means no, so...
I explained this to the nice lady, who said that out doctor needs to explain why she can't use them on an expedited appeal form, which she faxed to his office while we were talking.
But here's the thing. Botox retails at $1544 ($1200 at Sam's) a vial, and you need 2 for the injections, which are done every 3 months. The doctor also charges for performing the injections. Babygirl's old neurologist told us that the hospital she worked for got Botox in bulk for about $150/vial. Aimovig averages $715/month retail ($600-$650 with GoodRx), and the dose frequently needs to be doubled. Emgality retails at $726 - $929 ($559 with coupon), but the first month is always a double dose. So techincally, on paper, in retail, the newer meds are cheaper. But in reality, the Botox can be obtained for far less if the insurance company is bargaining for it. They were paying Nemours about $1500 total for Babygirl to get her injections. Three months of Aimovig is over $2000, and the Emgality is even more.
It seems that the purpose of the formulary here is to funnel money to the drug companies and not the doctors, but that may be a bit of paranoia on my part.
DeeDee
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