I have United as my health insurance. I have been told that United only covers 4 weeks of IV abx through the home health care company that I am using.
I generally get my oral prescriptions filled using a Caremark prescription plan. I guess my employer has chosen United as their health insurance plan and Caremark as their prescription plan.
I never really understood why I have two separate cards and assumed Caremark was owned by United or something, but now I think I am wrong about that. It never really mattered to me until now.
My question is... since United won't cover past 4 weeks of IV meds, will Caremark possibly cover more? Are United and Caremark separate companies or do they communicate with each other on patients?
I have called and called both United and Caremark this morning and it seems as though United and Caremark are completely separate. It also seems that Caremark may cover the IV medication (only meds, not administration) for as long as I need it. But then I was also told by my home health company that United would not allow Caremark to prescribe more than the 4 weeks of medication.
Can anyone explain the difference between health insurance plans and prescription plans... can they independent of each other?
Does anyone have experience with Caremark and IV coverage? Will they allow the medication for as long as I need it or do they also have 4 week limits on IV meds? Will they converse with United and find out I have already had 4 weeks of IV?
Thank you so much for your help! I am hoping I am not too confusing. I seem to have confused everyone I've spoken to on the phone this morning about this question.
V
Posted by Florence1 (Member # 22960) on :
I am so glad you asked this question......I have BCBS health insurance but caremark prescription plan......I have been worrying about this also.....
I did one month of rocephin in nov....but my LLMD may want me to go on IV when i see hime next week...........and i was wondering if it would go through caremark and same as you what will they cover.......
i will be interested to see the responses here....
Posted by soleil16 (Member # 16326) on :
I had Caremark prescription insurance up until recently. You are right, it is a separate company and administration from United.
Here is what I did with Caremark. On my formulary, I was able to get a one month supply of Rocephin for less than $10 (this may be different for your prescription plan- have your pharmacy run a claim for it). This was just for the vials of Rocephin- not saline to mix it, IV tubing, flushes, etc. I used Infuserve for those supplies. I then found a home health care company that did not require for me to purchase supplies through them.
Doing this, I was able to fill my prescription for Rocephin for as long as I needed. I also filled Tygacil this way, but it was not on any of the formulary tiers and so was much, much more expensive, though Caremark did cover part of it.
Good luck figuring this out! PM me if you have any other questions.
Posted by tonysgirl (Member # 11202) on :
I had Healthnet with Caremark as my prescription plan last year when I had IV. Healthnet didn't cover home healthcare because I was obtaining the meds from Caremark instead of it being ordered thru a home health agency.
This was both a plus and a con. First, I had to find my own nurse to change bandages etc. I lucked out and found a new friend in the process. I was struggling with Healthnet who refused to cover someone to change the bandage so I told them I was going to the emergency room before my picc became infected. At the emergency room, I met a wonderful nurse who thought the whole thing was ridiculous that they covered the picc being put in, but wouldn't cover the maintenance. I ended paying her about $25.00 a week and she came to my home or work and changed my picc bandage.
Now, with Caremark covering the meds, I just dropped off the prescription at CVS and they covered whatever the doc ordered. Nothing, absolutely nothing went thru Healthnet. This was good because they just continued to pay without following any of the insurance guidelines. If I were you, I wouldn't continue to make calls and just play stupid and drop off your scripts. The more you call, the bigger chance the two places may connect and they may put a limit on your prescriptions. Just my opinion.
Posted by lou (Member # 81) on :
Caremark was selected by United to provide your pharmacy benefits. They are one of the two biggest pharm providers. Medco is another one. If your ins plan has a mail order division, you can get meds thru it or thru a local retail pharmacy that accepts your insurance.
If an ins co decides it will not provide meds for lyme, that word will pass to its pharm arm too. Then the only avenue you might be able to use is the retail pharm, which generally has a copay. If you are refused there, then the only other way to get them is to self pay.
Posted by VB (Member # 16824) on :
Thank you all. So can you pick up IV meds at an actual retail pharmacy? Just bring in the prescription and have them fill it, like I would with pills? Or do I have to mail order them?
Thank you again so much for all of this awesome information.
Posted by marypart (Member # 27012) on :
We were able to get rocephin vials for awhile at our pharmacy, using the script from our doctor. Our insurance had cut us off for home health IV care, but the pharmacy plan gave us the vials.
Our doctor's office mixed them in bags and we did the iv's at home.
I didn't call the pharmacy insurance company. I just went to CVS and handed them the prescription.
Posted by Florence1 (Member # 22960) on :
up
Posted by tonysgirl (Member # 11202) on :
That's the toss up, either you use a home health agency and they will cover the usual 28 days. They provide the meds and administer them for you, change the bandage etc. This is all set up with your medical insurance, United Healthcare. If you get the script directly from your doctor, you can opt to get them thru pharmacare, but you will be on your own for the administration of the meds and the care of the site.
As I mentioned above, I had no problem with Pharmacare covering 5 1/2 months of meds for me. I also had no problem administering them myself, even at work. It was just finding someone to change the bandage. If you have a significant other, they maybe able to learn how to do it for you. My husband just couldn't do that part, he was too nervous about accidentally pulling out the line.
Posted by tonysgirl (Member # 11202) on :
I am sorry VB I neglected to answer your actual question, but yes, you pick up all of the IV meds at the pharmacy. That includes the saline flushes, the needles and the vials of meds.
Posted by soleil16 (Member # 16326) on :
And remember, if you have difficulty with the pharmacy providing flushes, needles or other supplies, there are other companies that can help with this. I love Infuserve's cheap prices.
So you may have three steps for setting up your infusions: 1. Get your vials of meds from a retail pharmacy, using Caremark insurance
2. Order flushes, IV bags, IV tubing from an infusion company (may have to pay for this yourself if insurance will not)
3. Set up your home health care through your medical insurance (I know with my medical insurance, once I had a PICC line, they paid for the maintenance)
Posted by VB (Member # 16824) on :
This is all so great. Thank you all very much for the input. This helps me tremendously.
Does anyone know if retail pharmacies carry all types of IV methods... for example, I use this ball thing that I can carry around with me (I forget what it's called). The ball holds the medicine so that it pumps out evenly over an hour.
Can I get any type of IV medication at a retail pharmacy or do they only have vials that I'll have to mix with something? I guess it's ok either way, I just know my LLMD prefers that ball for some reason.
Thanks so much again, VB
Posted by lyme987 (Member # 22148) on :
I also get my IV meds this way through caremark at the pharmacy. Everything you need, except the IV infusion set. I have no idea why you don't get that but I just order that online. It's pretty cheap and no script needed
I pretty much get as much as the drug as I need in the vial form. You do all the mixing yourself. I've become a pro
Good Luck!
Posted by VB (Member # 16824) on :
Good to know you can mix yourself! Hopefully my LLMD will be OK with that method vs the ball. Thank you