health insurance bingo: medication access
September 5, 2023 6:53 AM
Here's a question for other Americans who need regular meds, particularly if those are scheduled meds. If you've lived dividing your time between two different states, how did/do you handle getting your medications?
I'm facing a possible life shakeup and considering options. The states in question are far apart from each other. Snowbirds in RVs seem to manage this, so it must be doable. But I don't know how I would juggle an ACA policy (probably) and the necessity of keeping one psychiatrist who understands me and can prescribe my ADHD meds while meeting the various regulations, some of which require in-person visits.
If this issue is difficult enough, it will affect my choices. I've definitely made residential choices for health insurance in the past --
I'm facing a possible life shakeup and considering options. The states in question are far apart from each other. Snowbirds in RVs seem to manage this, so it must be doable. But I don't know how I would juggle an ACA policy (probably) and the necessity of keeping one psychiatrist who understands me and can prescribe my ADHD meds while meeting the various regulations, some of which require in-person visits.
If this issue is difficult enough, it will affect my choices. I've definitely made residential choices for health insurance in the past --
Will your regular psychiatrist consider prescribing you a 90 day supply?
The answer (I do this personally) may also be flying back for a weekend every few months for your in person 'yep I'm here, I did my labs, now give me my meds' and just pick up the meds or have them mailed to your other location.
posted by corb at 7:46 AM on September 5, 2023
The answer (I do this personally) may also be flying back for a weekend every few months for your in person 'yep I'm here, I did my labs, now give me my meds' and just pick up the meds or have them mailed to your other location.
posted by corb at 7:46 AM on September 5, 2023
I've sent you mefi mail. When it comes to scheduled meds, this is all so stupidly state-dependent that you'll probably need to research/confirm all the answers you get here, depending on which two states you're considering. E.g., in my state, there are no in-person visit requirements for scheduled meds, and my provider can electronically transmit prescriptions for scheduled meds to pharmacies in other states where it's legal to do so (though it's up to the discretion of the pharmacist whether or not they then fill the prescriptions), but I can't be prescribed 90-day supplies of scheduled meds, only 30-day. Basically every single aspect of this varies by state, though.
posted by unknowncommand at 8:13 AM on September 5, 2023
posted by unknowncommand at 8:13 AM on September 5, 2023
You'll have to talk to the psychiatrist about options regarding the in-person visit. I'm not sure how snowbirds and full-timers have managed this pre-pandemic, as I am using an online ADHD-specific service provider for appointments.
The thing you need to manage, from an "on paper" standpoint, is that your various caregivers will only have rights to prescribe in certain states, and even for telehealth you need to, ahem, "be" in the correct "place" for those meetings and you need to ask them to use a pharmacy that would make sense in the scenario in question and to which they would have Rx access. So you can't have a telemed appointment "in" New York and then have them call it in to a Walgreens in Kansas City, if there's no reciprocal agreement and they don't have a license to practice and prescribe in Kansas/Missouri. And you do NOT want to deal with transfers from the NY Walgreens of your choice to the KS Walgreens in your neighborhood. Even for non-controlled substances, it's like having the drugs driven to you in a clown car, and everyone who works at Walgreens is either mean as shit or so depressed they can barely type.
We travel fulltime and have a mail forwarding service (Personal MailBox is the current industry term) in our "domicile" state, which is a state that allows controlled psych meds to be handled with mail-order pharmacies (not all states do). The PMB bundles up and sends me my mail when I ask them to (tip: even without meds these places are awesome, they scan in the front of every envelope and you choose from that picture whether they should open and scan the contents, forward it, shred it, or recycle it - we forward like 4% of our mail). Gray area there, probably, but it's working for now.
You can ASK about 90-day supplies, but expect a no. The FDA is extremely crotchety about it so most pdocs won't do it for fear of audit, and most pharmacies won't fill it as policy.
All the rest of my meds I also use a mail-order pharmacy. On my old insurance, they used Express Scripts and it was fine and they had pretty good address management, my new insurance doesn't so I switched to - I hate it but the address management and shipping times are really good - Amazon Pharmacy. There are others. Don't use CVS, holy crap their mail order has gotten unusable. My PNP was completely unbothered by the Texas address of Amazon's pharmacy even though that is NOT the state either one of us was "in", which I assume means Amazon has greased all the state gears necessary, but that may just be a "mail order pharmacy" thing.
My husband has a biologic that has to be fedexed directly to us on cold packs, and we have no choice but Acreedo for that, but they have done a good job of managing the address changes every month, though he has to do this by phone for it to be right.
In all my digital nomad research, I think your only real choice is to establish "official" residence in the best state for your options, and then just happen to "travel" to the other really often. And that's a thing - people take care of family in other states, kids have custody stuff, people work more or less full-time on the road. It's not super weird if you don't make it weird on paper. Even travel nurse forums advise not telling any of your insurers you're moving around.
I would say be fairly honest with your pdoc, at least saying "I'm about to have to spend a bunch of time in Otherstate, do you have any suggestions for when I am unavoidably there when it's appointment time?" You never know - they may have a way for you to speak with them for the important advisory aspect of your treatment, but you can go somewhere to physically meet with an intermediary who completes the prescription process.
This is all way harder than it should be. I honestly had no idea how fucking complicated it is to exist in more than one state until we hit the road. Memail me if you have any state-specific questions and I will try to help or suggest good resources.
posted by Lyn Never at 8:14 AM on September 5, 2023
The thing you need to manage, from an "on paper" standpoint, is that your various caregivers will only have rights to prescribe in certain states, and even for telehealth you need to, ahem, "be" in the correct "place" for those meetings and you need to ask them to use a pharmacy that would make sense in the scenario in question and to which they would have Rx access. So you can't have a telemed appointment "in" New York and then have them call it in to a Walgreens in Kansas City, if there's no reciprocal agreement and they don't have a license to practice and prescribe in Kansas/Missouri. And you do NOT want to deal with transfers from the NY Walgreens of your choice to the KS Walgreens in your neighborhood. Even for non-controlled substances, it's like having the drugs driven to you in a clown car, and everyone who works at Walgreens is either mean as shit or so depressed they can barely type.
We travel fulltime and have a mail forwarding service (Personal MailBox is the current industry term) in our "domicile" state, which is a state that allows controlled psych meds to be handled with mail-order pharmacies (not all states do). The PMB bundles up and sends me my mail when I ask them to (tip: even without meds these places are awesome, they scan in the front of every envelope and you choose from that picture whether they should open and scan the contents, forward it, shred it, or recycle it - we forward like 4% of our mail). Gray area there, probably, but it's working for now.
You can ASK about 90-day supplies, but expect a no. The FDA is extremely crotchety about it so most pdocs won't do it for fear of audit, and most pharmacies won't fill it as policy.
All the rest of my meds I also use a mail-order pharmacy. On my old insurance, they used Express Scripts and it was fine and they had pretty good address management, my new insurance doesn't so I switched to - I hate it but the address management and shipping times are really good - Amazon Pharmacy. There are others. Don't use CVS, holy crap their mail order has gotten unusable. My PNP was completely unbothered by the Texas address of Amazon's pharmacy even though that is NOT the state either one of us was "in", which I assume means Amazon has greased all the state gears necessary, but that may just be a "mail order pharmacy" thing.
My husband has a biologic that has to be fedexed directly to us on cold packs, and we have no choice but Acreedo for that, but they have done a good job of managing the address changes every month, though he has to do this by phone for it to be right.
In all my digital nomad research, I think your only real choice is to establish "official" residence in the best state for your options, and then just happen to "travel" to the other really often. And that's a thing - people take care of family in other states, kids have custody stuff, people work more or less full-time on the road. It's not super weird if you don't make it weird on paper. Even travel nurse forums advise not telling any of your insurers you're moving around.
I would say be fairly honest with your pdoc, at least saying "I'm about to have to spend a bunch of time in Otherstate, do you have any suggestions for when I am unavoidably there when it's appointment time?" You never know - they may have a way for you to speak with them for the important advisory aspect of your treatment, but you can go somewhere to physically meet with an intermediary who completes the prescription process.
This is all way harder than it should be. I honestly had no idea how fucking complicated it is to exist in more than one state until we hit the road. Memail me if you have any state-specific questions and I will try to help or suggest good resources.
posted by Lyn Never at 8:14 AM on September 5, 2023
Also, echoing Lyn Never: CVS will always *always* be your worst option for this.
posted by unknowncommand at 8:22 AM on September 5, 2023
posted by unknowncommand at 8:22 AM on September 5, 2023
Hypothetically... mail order? Even Amazon have pharmacy affiliates that'll ship you medicine...
posted by kschang at 9:28 AM on September 5, 2023
posted by kschang at 9:28 AM on September 5, 2023
You can ASK about 90-day supplies, but expect a no. The FDA is extremely crotchety about it so most pdocs won't do it for fear of audit, and most pharmacies won't fill it as policy.
It's been 15 years since the federal rules changed to allow a 90 day fill policy on these medications, I dunno about state laws, but any provider being weird about it is probably maximizing their service fees at this point. Your prescription insurance however is likely to only allow you to fill 90 days via mail order, again, that's not the pharmacy policy that's the insurance policy.
If one of the states you're thinking of allows 90 day fills, I suspect you'll be able to manage this. I think many states allow this. But I also agree that just asking your current doctor point blank what they think you should do is a good idea.
posted by ch1x0r at 10:20 AM on September 5, 2023
It's been 15 years since the federal rules changed to allow a 90 day fill policy on these medications, I dunno about state laws, but any provider being weird about it is probably maximizing their service fees at this point. Your prescription insurance however is likely to only allow you to fill 90 days via mail order, again, that's not the pharmacy policy that's the insurance policy.
If one of the states you're thinking of allows 90 day fills, I suspect you'll be able to manage this. I think many states allow this. But I also agree that just asking your current doctor point blank what they think you should do is a good idea.
posted by ch1x0r at 10:20 AM on September 5, 2023
Thank you all so much! It seems like I will need to find out what is required for my particular meds and the states involved with an eye toward the regulations in force on the actual dates. So much nonsense. I appreciate all of your help!
posted by Countess Elena at 6:49 PM on September 5, 2023
posted by Countess Elena at 6:49 PM on September 5, 2023
I'd start by talking to your current prescribing doctor(s); they may have recommendations and/or relationships with doctors in your other state that may help things go smoother.
posted by spinifex23 at 9:55 PM on September 5, 2023
posted by spinifex23 at 9:55 PM on September 5, 2023
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Good luck.
posted by Silvery Fish at 7:42 AM on September 5, 2023