Sprycel rejected by exceeding expected amount?
Posted 15 June 2015 - 09:21 AM
I called Acreedo this morning to refill my Sprycel and the CSR said it would not go through because it has exceeded the expected, or maybe she said allotted, amount. They would request an override and she said they see it a lot.
Does anyone know what spurred this or what to expect? I have excellent coverage through work and I've never had this happen in more than four years of ordering expensive TKI's. I did notice that Sprycel recently went up from $9.7k per month to more than $10k, cost to insurance.
I'm on 100mg daily, if the script was for 50mg, does anyone know if that's cheaper?
Thanks for any advice.
Posted 15 June 2015 - 10:59 PM
I was told 20mg, 50mg, 100mg, and 140 mg of Sprycel are the same amount and require same co-pay responsibility.
I asked why this was so. I was told the drug is not priced by mg. When I went from 140 mg to 100 mg I thought I would get quite a discount, it was the exact same price.
Posted 16 June 2015 - 03:39 AM
The insurance companies prescription drug plans generally negotiate a substantial discount from the quoted list price. Copays are almost always based on tiers, which generally have fixed copays. On an annual basis, insurance companies may adjust the tiers on which specific drugs are based.
An exception is Medicare Part D plans, where, in the catastrophic phase, the copay is 5% of the amount the insurance company pays (often about $250-300/month, which means the insurance company is paying $5-6K/month). In catastrophic phase, the Federal government pays 80%.
Posted 16 June 2015 - 06:19 AM
I've been taking 50mg. for several years and there was no price break until the 50mg. point. I don't have a co-pay because my drugs are covered under our major medical and are subject to the out of pocket ceiling.
The price my insurance pays now is 50% of what 100mg. cost.
Medicare will not be my friend next year, I'm not looking forward to the switch.
"You can't change the direction of the wind but you can adjust your sails."
DX 12/08; Gleevec 400mg; liver toxicity; Sprycel 100mg.; CCyR 4/10; MMR 8/10; Pleural Effusion 2/12; Sprycel 50mg. Maintaining MMR; 2/15 PCRU; 8/16 drifting in and out of undetected like a wave meeting the shore. Retired 12/23/2016! 18 months of PCRU, most recent at Mayo on 7/25/17 was negative at their new sensitivity reporting of 0.003.<p>
Posted 16 June 2015 - 06:55 AM
Thanks everyone, sad news that lower mg isn't cheaper! Has anyone seen an insurance company suddenly reject the meds though? I'm hoping it was one of those weird automatic triggers and that everything will be OK and they'll get the override.
Now that the order is listed on the website, it does say everything is on track for the scheduled delivery, so maybe it's fine.
Posted 16 June 2015 - 09:02 AM
If you have had prior authorization and have not changed insurance coverage or providers you need to dispute the denial. Your oncologist will need to send in paperwork stating you need this medicine, this is part of their job and most have a department that handles these issues. I am battling BC/BS right now because I stayed with them but moved to a higher coverage plan with a higher premium. They are denying my one PH med because it was already authorized under the old plan.
The override is exactly what I am working through right now for the Adcirca, Make sure you get the override approved, then you have them go in to the system and use the pre-authorization for your Sprycel. If the oncologist sends new scripts in, it usually takes longer because they deny them and the former ones stating it is a double script.
Most of it is pain in the ass paperwork and it does not take long to clear up. I would suggest you stay in touch with Accredo every day, they are great but sometimes need to be reminded you are waiting. I have a great lady who is working with me on the Adcirca situation, she calls me every morning at 9 to see if it has been approved yet.
Best of luck. And be that squeaky wheel.
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