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I watched a news story on Channel 5 last night and needless to say was more than a little disappointed in how unfair the story was. It seems they wanted to tell one side only making the big bad insurance company the bad guy again. As a group insurance broker we work with employers and employees trying to manage benefits and costs. One the biggest challenges today is the high cost of prescriptions and all the new specialty prescriptions being prescribed. That is exactly what is happening in this story and Channel 5 makes it sound like the patient is going to go blind because of this new "policy change".
What BlueCross BlueShield of TN is not saying they are not going to cover this medication nor are they going to limit it. All they are doing is requiring members to purchase it through a Specialty Pharmacy where they have some control over the cost of the medication. This story is about Lucentis a shot that treats macular degeration. What they failed to mention is that the medication costs $2,000 per shot.
How much Dr. Awh charges BlueCross of TN for this medication I do not know. Nor, do I know how much the specialty pharmacy charges. I do suspect there is a pretty big difference in cost between the two and while patients and doctors may need to order the prescription the day before the office appointment the goal of BlueCross BlueShield of TN is help control costs and medical spending for all of their members.
I am writing this because we get a lot of calls from frustrated members because the expect their expensive treatments and prescriptions to be immediately covered with no questions asked. For the most part, everyone gets the treatment or prescription the doctor is ordering but I think it's important that the insurance companies do everything they can to make sure that treatment or Rx is necessary since it is saving me and our clients money.
Here are the resources I am using in this post.