prescription plan no longer covering medication-what to do?
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Anonymous
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I am a public school teacher in MCPS. I have an autoimmune disorder and have successfully been in remission since taking a medication for the last decade. I got a notice that this medication will no longer be
covered as of July 1. There is no generic version of my medication and I have unsuccessfully tried 2 out of the 4 alternative medications the insurance policy is offering instead. Buying the medication out of pocket will cost $1500 a month which would be very tough on my salary. My doctor wrote an appeal letter but it is possible that the appeal may be denied or that the process will take long beyond when I run out of my medication. The benefits director for MCPS is saying that he can't do anything to advocate for me. Is there anything else I can do? Without the medication, I will have cramping, diarrhea, intestinal inflamation, etc. and it will be difficult to do my job |
Anonymous
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When is your open enrollment? I would check to see if there's a plan you can pick that covers your medication.
If not, would it be possible to check on the ACA and see how costly it would be to pick a plan that covers your meds? I'm sorry you're in this situation, OP. Healthcare still sucks in this country, even if it's gotten better over the years. Still a LOOONG way to go to get to the level of European countries or Canada. |
Anonymous
| What does the insurance company say happens if you try the remaining two meds and they also do not work out for you? Have you checked to see what the price if the med is via GoodRX or does the manufacture offer any discounts/financial subsidies? |
Anonymous
| Absolutely try Good Rx |
Anonymous
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Buy from India. All Day Chemist.
It takes about a month to receive your delivery. You can also buy from Canada but it will be more expensive. Are you talking budesonide/entocort or uceris? A lot of folks with IBDs buy it from India. PS. I have an ACA plan. It is really pricey. I'm sure your plan as a teacher is significantly more affordable. |
Anonymous
| I am sorry, OP. Definitely try Good RX and if you know anyone going to India, maybe they can get the medicine for you. |
Anonymous
Price on the ACA depends on your ability to pay (income versus dependents). Also, ordering from online pharmacies is FRAUGHT with danger. You can never be certain that the meds delivered to you are free of contaminants, dosed correctly and are actually what you think they are. I understand the appeal of doing that, but there is a risk. |
Anonymous
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Thanks all- the medication is Pentasa and I take the maximum dosage for Crohn's---I looked into India but it seemed like Canada is more regulated--more likely to get the actual medication?
I looked on Good RX and it wasn't any cheaper. It looks like I would need to switch health insurance plans (switch to Kaiser) in order to get a different prescription plan...and I have reservations about switching to Kaiser as I am otherwise very happy with my insurance plan and the choice of doctors that I get to see . |
Anonymous
A generic version was just approved for that drug. Have you checked if that's covered? |
Anonymous
I get my insurance for very cheap on the ACA and I'm at Kaiser, with a chronic condition and daily meds. Kaiser has a bad reputation on DCUM because their mission is to keep costs low and therefore they regulate their medical care more than the average medical practice. But the doctors are good, and it's nice to have everything in the same building. I go with my kids, they have their well visits, we all do bloodwork, we go get glasses, whatever we need, apart from a few specialist appointments that are in a Kaiser location further away. With Covid, they've greatly expanded their telehealth offers, which is a godsend for me as my specialist doesn't actually need to see me most of the time, just talk to me and order bloodwork. If there is a significant price difference, I encourage you to switch to Kaiser. |
Anonymous
| OP do you have an out-of-pocket max on your insurance plan? And if you do, do the cost of prescriptions count towards it? |
Anonymous
| The manufacturer (Takeda) has a patient assistance program, look at the details on their website. Your income level may qualify for assistance and they also offer a coupon which can help with the out of pocket costs. Keep pursuing the insurance appeal, you may have to go through several appeals so don’t give up after the first round. |
Anonymous
| Is this CVS Caremark by chance? I have heard of them denying biologics left and right. The insurance person at the doctors office is actually filing a complaint. My husband contacted the person at his firm who deals with CVS and she basically pulled rank and now the prescription has been provisionally appealed at the insistence of the head physician at CVS. It’s unlikely that the appealed will be denied. If you can try that, do it. |
Anonymous
Oh sorry I just missed that the benefits director says he can’t do anything! He might be wrong about that. I wonder if you can just keep pestering him until he tries. How long has he been in that position? |
Anonymous
+1 FWIW a Kaiser GI correctly diagnosed my issue in one video visit where a pricey endoscopy and “top doc” weren’t able to help. |