I know the PCP issue gets brought up quite frequently here (especially with UW Health), but just wanted to make an FYI for Associated Physicians. I called today to see if I could get a new patient PCP appointment in Internal Medicine, and he said their new patient appointments are booking out into 2027, and if you want specifically a female provider they are booking into 2028.
UM HELLUURRR?????
Location: Wisconsin
[on behalf of my parents, as I manage their healthcare and prescriptions]
-parents are ~70 and on my father's employer healthcare plan (self-funded plan), so they were only on Medicare Part A. small-ish employer (more than 50 employees, though)
-employer switched to new PBM this year, they informed us of the change, and that "any drugs which cost $350 or more would need to be sourced internationally." - did not detail any actual changes in coverage
-mother has stage 4 cancer and her cancer recently progressed through the previous therapy, so she needed a new drug (an oral chemo).
-when the prescription for the new oral chemo was put in, we were informed it was not covered and would be $5,000. PBM uses "alternative funding" program to "source" medications all over the world for the cheapest, and has no time limit for how long they can take to get the drug or if they do at all
-after following up for weeks (me and the pharmacist), the PBM informed us that it would ultimately be up to the employer/administrator if they approved the medication. actually had to speak to the CEO of the company, who said "has she looked into alternatives like Medicare?"
-they approved a 1 month grace fill (was $300) at a local pharmacy, and we were told that it wouldn't be covered in the future unless they could find it through the alternate funding program. basically, each month we will never be certain IF they can get it, how long it will take, and what it will cost
-this led to a 5 week delay in her medication with stage 4 cancer (5 weeks from the prior authorization being put in by her provider to when it was approved by the CEO and filled by the pharmacy)
-one key piece that I'm stuck on is that I asked for the formulary from the PBM, they pointed me to it on their website, and it DID include the medication on the list of covered drugs, under a specialty tier (normally just means you source it through a specialty pharmacy instead of a retailer). was then told that the employer could make exceptions and didn't actually need to cover everything on the formulary, and couldn't provide me with a list of what was covered. I said what's the point of a formulary if it's not what is covered?
-almost none of the medications listed under cancer on the formulary are actually covered by this employer's plan when I search on the online portal
-the employer did not inform us of the impact in coverage of these cancer drugs (just that if it's over $350 it would be sourced internationally) when they changed PBM and during open enrollment this year
-I feel that this coverage is disproportionately affecting cancer patients/discriminating - and poor coverage is a way to force the medicare eligible employees to get off the insurance
-I think it's inappropriate the CEO of the company has information for exactly what prescriptions my parents use and that we had to speak directly to him to get approval for coverage
-I actually had to get them to agree to remove my mother from their insurance so I could enroll her in a medicare advantage plan to get coverage for her meds (in April)
- I feel the 5 week delay in medication let her cancer grow while it was untreated
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