Rx Coordination

Arthritis can take many forms and requires several different avenues for therapy. There are several avenues to attempt to reduce pain and improve mobility, from diet/lifestyle changes, to traditional pain relievers and advanced biologic therapy.

Our coordinators play a pivotal role in ensuring patients have access to the specialty medications they need. They coordinate the complexity of the prior authorization process with your insurance plan and are a bridge to your specialty pharmacy or in-office administered infusions/injections.

What is the difference between Medical vs Pharmacy benefits?

There are two ways medications can be covered, which is dependent on your insurance plan. It can be through your medical benefits (Part B) and/or your pharmacy benefits (Part D).

Medical Benefits

  • These are administered by a member of the care team in the office (injections or infusion therapy). 
  • Your doctor orders and pays for the drug, administers it to you and then bills your insurance for reimbursement.
  • In most cases, these medications are administered with less frequency than the self-administered medications and pills, giving you more time back in your schedule.
  • Alleviates the coordination burden off the patient as the provider’s office manages the medication, scheduling, and administration.

Pharmacy Benefits

  • These are generally self-administered injections and pills. 
  • Your doctor orders the drug by sending a prescription to your specialty pharmacy.
  • The specialty pharmacy fills and ships the medication to you or your doctors office (in select cases). 
  • Requires a heavier coordination burden on the patient as communication with your specialty pharmacy is required prior to shipping the medication to you.

Your doctor ordered you medication…What now?

  • Coordinators work with your insurance plan to get your medication(s) approved and processed. 
  • What to Expect: 
    • This process may take 4 weeks or more
    • Ensure the office has your updated medical and pharmacy insurance card
    • If your insurance changes, notify the Infusion & Biologics Coordinator Department right away. 
  • Contact information:
    • Infusion Department – Ph# (941) 556-5996
    • Biologics Coordinators (Pharmacy) – Ph# (941) 365-0770.
    • Biologics Coordinators (Pharmacy) – Fax # (833) 696-9425

  1. Your doctor orders medication and notifies the Patient Navigators.
  2. Our Patient Navigator team will meet with you to go over the process. They will verify the accuracy of the prescription, notes and other necessary items for benefits investigation submission. Once these items are complete, they send all information and communication to the coordinators.
  3. The coordinators team will complete the benefits investigation submission and then will complete a Prior Authorization when necessary, working with your insurance.
  4. Our coordinators can follow the prescription and authorization process from start to finish.

For Pharmacy Benefits: 

    • If Approved… 
      • Your specialty pharmacy will contact you to schedule your delivery (You must answer this call and verify delivery or the medication will not be shipped.) Do not opt in for automatic refills. This will often be from an 800 number.
      • If a medication is unaffordable please request the pharmacy place the prescription on hold and notify the Biologics Coordinator Department to discuss other options for access.
    • If Denied…
      • Our office will contact you.  
      • An appeal may be submitted.  
      • If continued denial then this may require a visit either in person or via Telehealth with your physician to discuss alternative options and best next steps.

 

  • For Medical Benefits:
    • If Approved… 
      • One of our infusion coordinators will contact you to schedule and to confirm benefits and provide an estimate of cost to you.
      • Copay cards are applied when applicable and if affordable to the patient, the coordinators will schedule the patient for their injection or infusion.
      • If a medication is approved but unaffordable then an appointment will be scheduled with your physician in person or via Telehealth to discuss other potential treatment options.
    • If Denied…
      • Our office will contact you.  
      • An appeal may be submitted.  
      • If continued denial then this may require a visit either in person or via Telehealth with your physician to discuss alternative options and best next steps.

To continue to serve the needs of the majority of our patients, we are unable to complete the Prior Authorizations for the following medications: 

  • All NSAIDS (Non-steroidal Anti-Inflammatory Drugs)
    • Aspirin (Disprin)
    • Ibuprofen (Nurofen)
    • Naproxen (Naprosyn)
    • Diclofenac (Voltaren) – oral or topical gel/solution
    • Celecoxib (Celebrex)
  • Folic acid
  • Vitamin D
  • Cyclobenzaprine (all muscle relaxants)
  • Tramadol
  • Hydrocodone/Oxycodone (Percocet, Oxycontin)
  • Lidocaine Patches
  • Prednisone
  • Pregabalin
  • Duloxetine
  • Methotrexate
  • Hydroxychloroquine (Plaquenil)
  • Acthar

 

Refer to these pharmacies offering coupons and discounts

FAQs

  • Used by prescription drug plans to evaluate medical necessity.

  • Pharmacies designed to deliver medications that require special handling, storage and distribution. You cannot drive to this type of pharmacy to pick up your medication, it is shipped to your home or your doctor’s office.

  • Savings programs offered by drug manufacturers to offset the cost to patients
  • Available for commercially insured patients only.

 

  • Designed to assist patients who do not qualify for copay card savings.  Based on the financial need of the patient and is available primarily for Medicare and uninsured patients. If approved, the medication is free to the patient.

  • Program that assists in providing medication to patients if prior authorization is denied.  
  • Available for commercial insurance patients and certain medications only.

 

Resources

Below are reliable resources from Creakyjoints and CSRO Coalition of State Rheumatology Organization.

Clicking on the tabs below links to the link from creakyjoints.

Copay Cards and Financial Assistance Insurance Issues Accumulator Adjustment, Alternative Funding and Maximizer Programs Prior authorization/Gold carding Pharmacy Benefit Managers (PBMs)

Our Biologic Coordination Team

Sarasota Arthritis Center uses Patient Navigators to guide patients on treatment plans and authorizations. Biologics and Infusion Coordinators handle prescription coordination, ensuring patients receive ordered treatments. Explore job opportunities by clicking the button below.

Careers

Take control of your symptoms today.

Rx Coordination Department 

Business Hours: Monday – Thursday 8am-5pm

  • Pharmacy Benefits Coordinators  #  941-365-0770
    • Teresa – ext 1103
    • Christine – ext 1132
  • Medical Benefit Coordinators (Infusion) # 941-556-5996