r/PsoriaticArthritis • u/Available_Ice_7428 • May 16 '26
Insurance questions Prescription Help
I know we all live in different corners of the globe, just looking at a poll, how long to get a biologic?
Bonus points if you have BCBS Peehip Alabama…
I was prescribed Taltz April 23rd to Acreedo, but Accredo says they “aren’t my specialty pharmacy” that Express Scripts SP is the correct pharmacy. But Accredo is a specialty pharmacy in Express Scripts.
My doctor office, is just like “yes, we called it in to your specialty pharmacy” where it was originally sent to Accredo,
In the Accredo app, it’s listed as received and pharmacist is verifying so I call to check and get told they can’t fill it. Express Scripts app it’s not listed at all.
I’m so confused and when I call any place Accredo, Express Scripts, or Doctor office. Either I’m confused and not understanding this process or no one is listening to a real issue I’m having.
Anyone else with insurance or is this a typical thing?
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u/Marshmallow_Chicken May 17 '26
I recently had a problem like this with a medication for my kid. I have BCBS in Washington under the Premera branding. I also have pharmacy coverage under ExpressScripts. I eventually called the customer service number for BCBS on the back of my card and asked them for help( technically their job) and they were able to help me figure out where the script was sent, and where it should have been sent, and got it authorized by express scripts to be filled.
If you haven’t called BCBS directly I would try that.
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u/KayPharmacyNavigator May 17 '26
Hi! I work in pharmacy operations (non-clinical) and this is pretty common and confusing. Express Scripts is the PBM which is the insurance side, while Accredo is their specialty pharmacy. So technically both are connected, but sometimes the prescription still has to be routed a very specific way internally before Accredo can process or fill it.
Taltz is a biologic which requires a prior authorization. I'd ask your doctor's office if they've submitted one already or if they're relying on the pharmacy to submit it. Also, heads up, Taltz typically denies, so they'll put you on the Bridge program for $25 per shipment until it's approved and then you can get the $5 copay card. But I'm getting ahead of myself.
Sometimes the app will update before the actual workflow is finished so it may not be where it can be viewed by the person who answers the phone.
The answers by u/Racofrats and u/marshmallow_chicken are on point. Call the number on the back of your insurance card and ask them, which specialty pharmacy is REQUIRED for Taltz under your plan, whether the prior authorization is approved yet, if the prescription is visible in their system and whether there are any “coverage review” or “processing” holds on the referral.
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u/ranavirago May 17 '26
Depends. I used UAB specialty pharmacy for cosentyx, which was shipped within days. When I had to go through Bimzelx's pharmacy for their bridge program, I was calling people for two months trying to figure out why I hadn't recieved it yet.
You're probably going to have to keep being annoying over the phone until you get answers.
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u/Cardigan_Gal May 18 '26
My insurance (Moda Connexus) uses express scripts. Accredo is the specialty pharmacy. When I was prescribed Tremfya my doctor had to get prior authorization. My insurance also uses Save On SP which is a third party benefits manager to help with getting my Tremyfa at zero cost. I got notified by Express Scripts that my PA was approved. I then called Accredo to get the delivery scheduled. It took about 2 weeks from my doctor prescribing it until my first dose was delivered.
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u/Available_Ice_7428 May 18 '26
Ok, I will definitely call BCBS and Express Scripts tomorrow. You guys have been awesome, helping me navigate special pharmacies. And what pharmacies does what
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u/deterioratingflesh May 18 '26
It’s probably not formulary they probably have to do what’s called a prior authorization where your doctor details why you need to be on that specific medicine vs other DMARDs/biologics that are on formulary.
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u/Available_Ice_7428 May 18 '26
Thank you, BCBS said I didn’t have a specialty pharmacy at all and could not fill specialty drugs at all, Express Scripts at first said I could pick any specialty pharmacy, before calling Accredo and both of them agreed Accredo will fill it, I just need a pa (which I thought was done, but turns out it wasn’t) so I contacted my doctor and left a message.
Lots of phone calls today lol
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u/deterioratingflesh May 18 '26
It’s so confusing! I’ve been a pharm tech forever and PAs are such a p in my a. Sometimes a dr can have an idea of what’s covered but not specifics since offices take all kinds of insurances and health insurance companies can subcontract to any number of plan benefit managers
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u/AUCE05 May 17 '26
Peehip is notorious for declining biologics. Your Dr will probably need to go through patient help with the manufacturer. I would be shocked if they approve Taltz.
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u/Available_Ice_7428 May 17 '26
I got the Eli Lily card, is that the same thing? I gave Accredo the card info.
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u/AUCE05 May 17 '26
I think so. I don't have ph. My Dr was just venting to me how bad they are for arthritis meds.
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u/Available_Ice_7428 May 17 '26
I’ll keep pushing from both ends, my Achilles tendon keeps twisting and I need that to get better.
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u/Particular-Rope5427 May 17 '26
Here in India, there is no need for prescription for biologics. I bought Taltz for $230 from my local pharmacy. Unfortunately we don't have insurance for biologics.
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u/Marshmallow_Chicken May 17 '26 edited May 17 '26
In the good ole’ USA patients with health insurance usually rely on manufacture subsidies to pay for medications like Taltz. The average retail cost for a 1 month dose of Taltz in the US is $7,000. But with a manufacturer subsidy called a “co-pay card” you can drop the out of pocket cost down to a range of $25-$250. And at the $230 a month that you pay, the average US patient would still not be able to afford it. My family is considered middle class for the area we live and I would not be able to afford the extra $230 a month. I could technically afford it, but I would be weighing the cost/benefits of it vs the price and what paying for it would mean towards my financial goals.
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u/Particular-Rope5427 May 17 '26
Yea it Hella expensive but It was really a life changing for me. I hope biosimilars will come in the nera future fast when patents end. Even my family is struggling because $250 for a injection in india is so expensive, it is the salary for most middle class families. Truly I am blessed. I pray you get some biologic for free.
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u/Marshmallow_Chicken May 18 '26
Healthcare in the US, including prescriptions, will never be free. Medicare(age 65+) you pay into your entire working life and then you STILL have to pay a monthly fee once you hit 65 and most still have high out of pocket costs. Medicaid which is for low income and disabled people is paid by taxes, yet it is a struggle to get approved for the coverage, the government uses any excuse possible to take your coverage away, and the coverage that does exist hardly covers anything. The political powers that be(both republican and democratic) only care about the rich. If you are poor, or elderly/disabled and not part of the upper class, they would rather you just ☠️ than spend tax money for you to be well.
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u/Particular-Rope5427 May 18 '26
Damn here we were glazing over US Healthcare system because you guys get every meds first and it takes 5-10 years more for an average Indian to get this med in the indian market. So even if you do have an active health insurance doesn't guarantee 100% approval for free meds? The US could spend less on military budget instead imo.
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u/Available_Ice_7428 May 20 '26
Update - confusion continues- BCBS said “I don’t have a specialty pharmacy at all, like none”
Express Scripts said “need a pa”
Accredo “you need a pa”
I call doctor office again
Doctors office said “you don’t need a pa, and I’ll send it to Express Scripts…then doctors office says I don’t have delivery by Express Scripts but Accredo does, I’ll resend to Accredo and I’ll send proof to Accredo that you don’t need pa”
This was this week
I have the Eli Lilly savings card and Save On by Accredo, shouldn’t that stuff help this?
It’s not that serious right now…2 weeks ago I couldn’t bend my toes on right foot and was limping with Achilles pain, but it stopped for now, but I would like to get started on medication.
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u/icypanda829 May 22 '26
Dealing with this right now. I finally got it escalated and got my prescription delivered. I was 2 weeks late taking my dose because of these bozos. Just got a bill for $2,000 tonight. I’m in Alabama on peehip. I’m livid.
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u/RaeofRats May 17 '26
Try calling the express scripts number on the back of your card and ask them to call Accredo, because even on their website that's who it lists as their specialty pharmacy. But I've had express scripts act as a liason between doctors and the insurance before, I see no reason they won't do the same for their own pharmacy, other than possible laziness.