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HRT Support Drugs (Arimidex and HCG) Insurance - My Head Hurts

Blesum

Blesum

Maestro
I've been going around and around with my insurance company (blue shield) and a local compounding company trying to get them to cover my HRT support drugs of Arimidex (high E2 levels) and HCG (stablize hormones and nut size).

In another thread I mentioned the local Rite Aid pharmacy store wouldn't give me either products despite my handing them scrips for both from my Endo. Apparently my insurance company denied covering them despite covering the testosterone cyp.

I sent them an email on their site asking about coverage and this is the gist of an 5 or so page email of what I got back:

Dear XXX

Thank you for your pharmacy benefits inquiry.

Arimidex is a Brand Name formulary prescription drug that is
restricted to females greater than 45 years of age. A prior
authorization would be required to have the Arimidex covered
due to the restriction indicated. According to our records a
request for authorization of Arimidex was made on February 05,
2007 and was denied on February 06, 2007. You or your
prescribing physician can contact our Pharmacy Services
department at (800) 535-9481 for information regarding the
denial. Your prescribing physician can provide additional
information and/or appeal the denial of the Arimidex by
contacting the Pharmacy Services department at (800) 535-9481.

According to our records there is no attempt for a
prescription for Tussafed-HCG to be filled recently, during
the 2007 calendar year. Tussafed-HCG is a Non-formulary Brand
Name prescription drug with a generic available called
phenylephrine-hydrocodone-gg. Non-formulary drugs require
prior authorization to be covered by your plan.

You are covered for outpatient prescriptions if they are:
(a) Prescribed by a Physician,
(b) In the Drug Formulary, and
(c) Obtained from a Participating Pharmacy.

You have the following copayments for outpatient prescription
drugs when obtained at a Participating Pharmacy:

Generic: $5 copayment per RX/prescription
Brand Name-formulary: $15 copayment per RX/prescription

You are covered for outpatient prescriptions through Mail
Service if they are:
(a) Prescribed by a Physician,
(b) In the Drug Formulary,
(c) Obtained from Express (r)Scripts Pharmacy, and
(d) Prescribed for a chronic condition and your dosage has
been stabilized.

You have the following copayments for outpatient prescription
drugs when obtained through the mail service:

Generic: $10 copayment per RX/prescription
Brand Name-formulary: $30 copayment per RX/prescription

Non formulary drugs may also be covered if prior authorization
is obtained.
Click to expand...

I asked my Endo to call them up and find out why I was denied the Arimidex and to please start the appeal process if possible. Is there anything else I can, or should be doing?

I also don't quite understand what Blue Shield is telling me about the HCG - Am I covered or am I not? It seems like they are saying I might need prior authorization (how do I get that?), that I am not covered for non-formulary brand without said authorization but there is a generic available (phenylephrine-hydrocodone-gg) which might be formulary and therefore covered but they're not saying. I'm confused and my head hurts.

I just want do do things right. Can anybody figure out exactly what they're saying and what I need/should do?

Many thanks,

Blesum
 
Hard As Nails,

How did you start the process and was it through a local pharmacy store or a compounding company?

-Blesum
 
BTW, information is power. I'm NOT source posting so I shouldn't get in trouble for this but wanted to share the prices I got for these items from the local compounding company without coverage:

In any case, the HCG is $59.95 for a vial and the Arimidex (commercial product) is $45.89 for 4 tablets.

Good prices? Bad? If worst comes to worst and I end up paying out of my pocket 100%, should I go with this?

-Blesum

Edit: it's my understanding that the Arimidex is 1 mg per tablet, and I'm planning to start at .25 every 3 days if memory serves me correctly so these 4 tablets would last me only 48 days. Almost $3 per 1/4 of a tablet. Sucks. Not sure how long a "vial" would last me at 250 IU every 3 days and I'm scared to find out but do tell if anybody knows.
 
Blesum said:
Hard As Nails,

How did you start the process and was it through a local pharmacy store or a compounding company?

-Blesum
Click to expand...
I handed the the pharacist the prescription and she came back to me and said that my insurance would have to check on the numbers and I just paid it like 75 bucks and then sent a claim form in for reinbursemnt and got a check back from them..
 
Blesum said:
BTW, information is power. I'm NOT source posting so I shouldn't get in trouble for this but wanted to share the prices I got for these items from the local compounding company without coverage:

In any case, the HCG is $59.95 for a vial and the Arimidex (commercial product) is $45.89 for 4 tablets.

Good prices? Bad? If worst comes to worst and I end up paying out of my pocket 100%, should I go with this?

-Blesum
Click to expand...

lat time I checked few monts ago it was like 7 or 8 bucks per tabs, but if you only have to take a tab a week its well worth it.
 
Blesum,
The pre-authorization for your hCG has to come from your physician. Someone from his office MUST call your insurance company BEFORE you go to the pharmacy to fill it. Your MD will have to provide the treatment code. Then, it should go through.
The Arimidex is a different story. Since your use is "off-label", it typically isn't covered. Keep checking around because your prices seem high. Call all of your local pharmacies and check prices without going through insurance (as long as you have the script). Good luck.

Mike
 
Thanks MikandRea,

I've emailed my endo asking him to follow up on the HCG authorization.

Nice prices! Still hoping my insurance company will somehow take care of me but I've bookmarked that site just in case.

-Blesum
 
You my friend are in a world of good luck.

I can direct you to a place for armidex. Year long supply for 50 bucks. PM me.

BTW, its nice to know Im not the only ripped guy with an e2 problem. I was thinking I was some sort of freak.
 
Yeah, but can you trust a "research chemical" not intended for human use? I'm not trying to flame anyone, but I'd be nervous using the research liquids. How can you be sure there's nothing freaky in there!!! And, truly I'm asking. People on here have been on it for a while. What kind of luck do you have?

Mike
 
mikandrea said:
Yeah, but can you trust a "research chemical" not intended for human use? I'm not trying to flame anyone, but I'd be nervous using the research liquids. How can you be sure there's nothing freaky in there!!! And, truly I'm asking. People on here have been on it for a while. What kind of luck do you have?

Mike
Click to expand...

the reasearch liquids are fine they work! If that is your only option it will do.
 
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