Taltz - Kat's journey continues

[Kat]

Okay so I got the call today from the pharmacy. For anyone interested the way the co pay works in the US is that if you are approved you will pay as little as $5 each shipment and if you aren't approved you won't pay over $25. So it's very different from the way Stelara worked and Cosentyx. So far all of the three biologics for me have been handled differently in billing. It's a bit crazy!

They are going to ship and I've agreed to pay $25 for the first shipment so as not to wait. I'll have to call the Taltz people to see if I get approved for the $5 co pay. If I do then future shipments will only be $5, if not they will remain at $25. No, I have no clue as to why it's that way. But at least it's affordable. (Stelara and Cosentyx were no cost to me) These rates have been approved for the next 36 months, not sure what happens after that but we'll see how it works and worry about that later.

I will hold off taking any pictures until the day of my first injection. The schedule will be 2 injections the first time (starter dose, each injection is 80mg) then 1 injection every two weeks for 3 months and the 1 injection every 4 weeks for maintenance.

[Fred]

Very strange system.

Good luck Kat I hope this one works for you.

I have subscribed to this thread and hope to see good results.

Oh and don't forget to change your treatment in your profile.

[jiml]

Nice to know a bit about your system Kat .....all seems very strange to us over this side of the pond ....how any of you Americans understand it is beyond me
But at least it's on it's way Kat and hopefully it will give the clearance and stop the itching for you
Good luck I look forward to following your progress

[Kat]

Yes, it's very difficult to understand.

Stelara was buy and bill. The coverage was through our medical insurance and basically the hospital buys it (at a reduced cost I imagine) and then sells it to me through my insurance. That is why I had to go to the hospital for those injections.

Cosentyx was through our prescription insurance (NOT medical insurance) and that insurance required we use their specialty pharmacy. The co pay was through Cosentyx and after the co pay they had a credit card additional co pay if needed PLUS my prescription insurance had a program called "save on" which agreed to cover any costs not covered by any of the co pays.

Taltz is also through our prescription insurance however, it looks like the specialty pharmacy that the doctor sent it to will handle it (they sent the Cosentyx through the same one but our prescription insurance said no, we had to use theirs) and they have given me the info to call Taltz to apply for co pay. If approved it's the $5, if not approved it's $25. I explained to them that our prescription insurance required the Costentyx to go through their own specialty pharmacy but they are sending out the Taltz and didn't think it was a problem, let's hope they are correct.

So I don't understand any of that! Three biologics all handled differently by insurance and how they bill. I filed medical insurance years ago for a hospital but things were MUCH simpler then. I believe that a lot of it has to do with the companies that are making the biologics and how they manage their co pays since it seems each of them offer some type of co pay program. Then the doctors find the "work around" on how best to bill it to the patient's insurance to make the most of the coverage. Or something like that anyway, I'm just glad I no longer work in insurance as it's way too complicated anymore!

But hopefully this will be the one that works for me.

[Caroline]

Surely do hope this one works for you Kat.

And well... your insurance system... even with your explanation it is far too difficult for me to understand.

[Kat]

Surely do hope this one works for you Kat.

And well... your insurance system... even with your explanation it is far too difficult for me to understand. 

It's fine Caroline, even with my explanation "I" still don't get it!!

I did call and the Taltz people had received paperwork from my doctor and I was approved for the $5 co pay. My GUESS is that is has to do with insurance on whether you pay $5 or $25 but that's just a guess.

[Kat]

Well I got my Taltz last Thursday. Cosentyx had a better "Welcome" package with their travel bag etc. Taltz sent me a box of three injection pens and some paperwork explaining how to use, etc.

My Cosentyx would have been due last Wednesday so I'm good to go, not sure why I am holding off other than I have a busy weekend planned and don't want to end up feeling off should I have any side effects with the new medication. I plan to inject tomorrow evening or Monday at the latest.

[Fred]

Good luck Kat.

[Kat]

Well, it will be Monday before I inject. Received a letter today from my prescription plan. It states the following:

"We have declined on behalf of your plan to provide benefits, in whole or in part, for Taltz autoinjector 80 mg/ml AUTO INJCT."

The reason listed is:

The requested drug is NON-PREFERRED and coverage is not authorized under the plan. The non-preferred drug is covered when documentation has been provided that the patient has tried THREE of Cosentyx, Humira, Otezla, Stelara SC, and Tremfya.

Now I specifically told the specialty pharmacy to check with my insurance plan. So either:
A) I have a big problem
B) My prescription plan denying coverage doesn't affect the $5 - $25 copay (I was approved for the $5, although not sure why as that info came from the doctor's office)

But I will call them Monday before injecting because if they think I'm paying more than the agreed price, they will get it back!!! Although I don't think that will be the case, but I'm not taking any chances until I talk to them as I just don't know how this is working regarding insurance, payment, etc. I was assured my cost would never be over $25 so everything should be okay but still.... better wait and know for sure!

[Fred]

So complicated, don't these people appreciate that people with psoriasis shoud avid stress.

Yes I would hold of till you are sure. These things cost huge amounts of money and you don't want to be paying the full price for it.