A patient at home tested positive for Covid-19. The symptoms were simple. The GP's call was answered quickly and the Paxlovid script was delivered to the selected local pharmacy. The good news: the script will be ready to go in a few hours. The patient's husband went to a nearby Walmart pharmacy to pick up the medication. That's when he learned the drug wasn't part of their plan, so his insurance wouldn't cover it. He faced a $1,600 request to pay for the drug, which was said to reduce the risk of vulnerable people developing severe Covid-19. His wife is included in this category as she is over 60 years of age. Since he had been vaccinated and his age was the only risk factor, they decided to monitor his symptoms at home with fluids and plenty of rest.
Thus begins a complex two-day journey for patients through insurance programs and pharmaceutical care. Thinking something was wrong with the coverage selection because a drug like Paxlovide was not included in the formulary, the patient went online to inquire about the plan's coverage. This road is dry. He then contacted the insurance company to find out why such a valuable drug was not covered. After a long wait, the officer answered the phone. The answer was unsatisfying: the plan simply didn't cover the drug; Is there anything else you can do to help me? This is a request to speak with a supervisor, but only after submitting a separate request Regarding the latter, the response period was three days to ensure that an exception was made for Paklovid. Because the drug must be taken within five days of the onset of symptoms, the window of effectiveness may close before a positive verdict is reached.
After two motions and at least 40 minutes of waiting, the next conductor took his turn and had to repeat the whole story. Supervisor Chanita made an interesting point. After the federal government stopped covering paxlovide in early November, Pfizer offered the drug commercially at a discount to patients. This increases total drug costs for uninsured patients and those on Medicaid or Medicare. The next question is how did Pfizer hide the drug and why no one was aware of this fact or the process of getting support.
Chanita offers a patient assistance program hotline. Your answer to the second question is interesting. Although it was implemented two months ago and all the major players who knew it was coming, major insurers perceived it as a "new development". Because it was "new," Chanita wasn't surprised that few people knew about the process: not drug providers, but insurance company employees and even Walmart pharmacy technicians. He said he would discuss the matter with management, believing concerns raised by critically ill patients should be addressed.
So the next step was to call the Pfizer patient care line. After another long wait, the patient spoke to a well-meaning but limited English-speaking representative who answered questions and wrote down basic information without too much repetition. The registration process takes about two hours, and patients understand that by waiving their HIPAA rights, they are allowing Pfizer to actively market and share information widely with outside parties about the drugs that Pfizer provides. Pfizer. for free. Not surprisingly, this does not benefit the patient. What is the cost of healthcare privacy? $1600? More than that? At this time the manager asked to speak with him. Another iteration led to another escalation, this time to a good Englishman who understood the situation. It is agreed that a patient may waive his right to receive Pfizer coverage and request a waiver of his right after the drug is dispensed. The plan worked.
Let's think about the implications of this experience for the general covid-19 patients and the health of the country as a whole. Most people can't afford to write a $1,600 check to Paxlovid. The road to figuring out how to cover medication costs was tough. How many people have the time, patience and attention to understand the intricacies of the insurance system, or to understand that a company has a duty to provide unlimited personal health information for free.
Kudos to Pfizer for making paxlovid widely available to health plans a year after the federal government decided to stop reimbursement entirely. But where was the communication effort to ensure that medical journalists knew the details of their patients to cover? Where were the insurance companies when communicating information to members about how to provide coverage/access if patients are eligible for Paxlovid? Drug prices and public health concerns as Covid-19 continues to cause hospitalizations and, in some cases, deaths, can and will dominate the issue before November 3rd. Failure because "the change process is still in the beginning, so people don't know" is another indicator of lack of accountability and coordination. We want the best.
