Family and Caregiver Schizophrenia Discussion Forum

Anyone have experience getting Blue Cross to process Symbyax on part D?


#1

We work on LEAP for all this time, finally get to a doctor and can’t get Blue Cross medicare part D to release the medication. It was originally prescribed one week ago.

I know from experience with my son’s other health condition, that they throw out all these forms for the doctors to fill out and they scan them over looking for any errors so they can find an excuse to NOT issue the medication, especially if it is expensive.

I plan to tackle them tomorrow, starting with Blue Cross to make sure they are requesting the form NOT the pharmacy’s processing center - which it can be sometimes.

But has anyone fought this fight before? All the pharmacy would tell me so far is that they need a diagnosis to show its a needed medication.

So very, very frustrating. One step forward and a wall appears.


#2

Oh, that’s frustrating.

I never heard of the medication and looked it up.

It’s basically a combination of zyprexa and prozac…

Can the doctor write separate scripts or at least the zyprexa?


#3

I am assuming there is a reason doctor and patient agreed on this medication. Surely, right? Its a good idea for tomorrow if I can’t get anything moved. Odds are he won’t take the zyprexa alone. Remember he is not sick.


#4

Yes, I would definitely think the doctor has a reason for prescribing.

I agree it’s best to try to get the prescription filled as written.

How much does the med cost without insurance: https://www.goodrx.com/symbyax


#5

At his pharmacy its $419 without insurance or a coupon. I am afraid if I used one of those coupons - btw- what a great resource and it worked and what if we still couldn’t get the med approved for next month. Currently his therapist alone costs me nearly $400 a month and now a psychiatrist bill on top of it? Neither of them are covered by his insurance.

I will stay the course of getting as much of his medical needs covered by insurance as possible.

Surely other people on medicare part D Blue Cross may have some experience - if not, I will gain some.


#6

I don’t know about your son’s specific medical coverage plan, but when my son was approved for SSI, it also made him approved for Medicaid that allowed for free or close to free AP prescription drugs, doc visits, hospital stays, etc.

Does your son get SSI or SSDI?


#7

Regarding the concern that he won’t take Zyprexa because “He’s not sick”, you could tell him “you heard that Zyprexa is great for stabilizing moods” (which in our experience it is/was).

And interestingly, even though my son stopped taking Zyprexa almost 3 weeks ago, his mood has remained stable for the most part.


#8

Blue Cross has case managers. Does he have one there?


#9

My son gets ssdi and ssi which means he has medicaid, medicare and medicare part d. The state and the federal money is allocated specifically. His medicaid will pick up whatever is left over, but whatever comes under medicare part D is expected to be processed under the part D.

The problem here is helping the provider make the right choices to get the formulary and tier exception granted. The combined drug is not covered by the plan.

If they can get all the answers “correct” it will go through. I was hoping someone knew the answers.


#10

I am glad your son has stayed stable.

That the doctor and my son have found a med that he agrees to take is rather amazing. i would guess that the doctor is sliding the zyprexa in with the prozac so he has to take both. The compounding part is the expensive part and I suspect the crucial part to get my son on the med.


#11

He has a case manager for his UHC but not, that I am aware of, for his BCBS part D. That will be my next question if the latest information doesn’t work. With this sort of thing I have found in the past I have to work my way up or down the path, first getting an official denial at one level before I can press on.

This morning I have found out that the provider has not yet submitted the exceptions forms. So I head there next.


#12

If they do try a Zyprexa injection, federal guidlines for safety say that you have to monitored in a clinical setting for either 2 or 4 hours after the shot.

A few people died because the injection did more of an immediate release instead of a gradual release.

The hospital wanted to try that as an injection, but his outpatient doctor won’t prescribe or administer it because of the dangers & requirements.

But, Zyprexa & Prozac are a good combo - my son was on those 2 drugs for years.


#13

I sent the doctor the formulary and a timeline write up of the past 15 years and now the compound med is out - didn’t look like it would get approved anyway - would have been quite the multi-week slog to make it happen - no history of other meds not working would have made it difficult since there is no history of actually attempted meds at all. New combo is Invega, Prozac and Ativan. What do you think of this combo?


#14

They’re only giving you a problem with the Invega because it’s a shot and it’s expensive.

If I remember correctly, the initial 117 mg maintenance does is like $1500 total in our prescription plan
Then, if you don’t have insurance that $1500 probably goes up some.

Risperdal metabolizes into the same chemical that’s in Invega. I think it might be generic now. It is a 2-week shot instead of a monthly shot though.

For anyone who has private health insurance, they can go to the following link to get a coupon you can use 13 times that will drop the price of the Invega Sustenna to $10 per prescription.
https://sservices.trialcard.com/Coupon/Janssen/Janssenenrollment?strPromotion=Sustenna

I’m guessing Medicare/Medicaid would pay at 100% if it’s approved. They pay it for my friend’s son anyway.


#15

They issued the Invega right away - its not the shot. The problem was the compound medication of Zyprexa and Prozac, not covered by the formulary, I have learned that compound meds are expensive.

We might have hit a med limit, one of the meds we had to pay for, it wasn’t expensive. Jeb will take a total of 9 meds now.


#16

I know you might not want to but can you change to a med d plan that covers it? Btw sorry to hear he’s on so much medication.


#17

Wow! 9 meds! How does he feel about taking that many? I just can’t imagine…was difficult to get my son to take the one every night. Praying that they don’t add on to ours.


#18

That is a good suggestion - if I recall correctly, since he is on medicaid, he can change his part D provider monthly, he doesn’t have to wait for the open enrollment period. I totally forgot about that. Now we have meds issued, but I will check through the different formularies, I have to check them for his immunosuppressives each year.


#19

Jeb doesn’t have any insight on the norm. My FtF leader told us that insight can fluctuate. His argument on some days for not taking meds, has been that he takes too many dangerous meds already. He is correct, that is a rational argument. Three of his meds are seriously dangerous drugs. All three are known carcinogens, and cancer is just one of a long list of risks. Now you add on 3 more drugs with side effects and risks of their own.


#20

Right. I don’t qualify for Medicaid but I do get extra help with med d. I think my paperwork said the same thing. Where I could switch med d plans at anytime. Now hopefully other med d plans will cover his compound medication.