I finally got to see a Dr. yesterday. My A1C is 8.6, and of course my insurance won't cover the med she prescribed for me. My blood pressure was 173 over 100, and of course my insurance won't cover the med she prescribed for me. Some days I just get tired of fighting. Nearly 10 years I've been doing this now. And yes, I know, some of you have been doing it most of your lives. Anyway, that's my rant for the day. I just want to be normal again, but alas, I can't go back.
What do you mean insurance won't cover the medication? Is it just that you have a high deductible? It would seem these medications are medically necessary. It seems absurd they won't cover the medications. Will your Dr. write a letter of medical necessity?
Would there be alternative medications that the insurance would cover?
The medications are 350 bucks for a 30 day supply. She said they can appeal it and try to get a pre-authorization on it. otherwise, she has to prescribe something that isn't so expensive-and probably doesn't work as well...
Yes, she can prescribe something else, but it may not be as good as the other one. It just seems like a scam to me that the insurance has the authority to turn you down for something that works well because it's too expensive, for something cheaper that doesn't do the job as well.
This new formulary that the insurance are using to force you to use thier "preferred" drug is driving me crazy! I "prefer" my doctor decide what drug would work best for me. Isn't that what the doctor went to school for? I am sure the accountant who wants me to use the drug that the insurance has the best deal on has no idea what drugs would work best on me! I wonder if one can sue them for praticing medicine without a license?
In the US, payers are parasites. They bring nothing of value to health care. They simply cost.
It is always important to understand which medications your insurance considers preferred on their formulary. And the cost of the medications may be high, but your insurance is likely to have a negotiated rate. Until you reach you deductible, you will be expected to cover the entier negotiated rate. You cab reduce the out of pocket expenses by working any of the cost elements along this chain.
Some insurances definitely suck, but let's not treat doctors as though they were somehow always rationally prescribing what was in the best interests of their patients. There's a reason drug companies spend all that money on fancy junkets to Hawaii and nice dinners and attractive but often not particularly educated reps who drop by the doctors' offices, and it ain't because they just like being nice to doctors. I recently stumbled across a fascinating website that provides transparency on this, you can type in doctors' names and see what sort of perks they've received, the variation is fascinating, some take very little and others take tons. Can't remember what the website was, though. :(
If you're willing to share, what are the meds that are being denied and what are the covered alternatives? Both the BG and BP numbers are serious, the BG poses more of a long-run risk, the BP a bit more of a near-term one if it's sustained, and is pretty close to numbers that might get you hospitalized. My two cents, anyway, not an MD, but with some relevant professional background on this stuff.
Bobby, I am so sorry you are facing this issue. There are some things you might consider. Likely your insurance denied the medications because it is not part of the plan formulary. The formulary, likely contains preferred alternative drugs. My Doctor for instance prescribed me to use Nexium. However they prefer Prevaced. I would prefer to use Nexium so I have three choices, use the Prevacid which is fully covered that requires the Doctor's agreement, use the Nexium (this gets only partial coverage causing a much higher cost for the drug. or go without. The pharmacist suggested I contact my doctor, and he quickly changed the prescription saying he had no preference unless I did. Bottom line the Previciad is fine. Much ado about not much of anything in the end. I suggest you talk to your Pharmacist. They can give solid advice that will help you speak to your doctor if you need too.
Good luck and please let us know how things are going.
I agree with Rick. I would research the various covered drugs yourself and ask your pharmacist for help also. The only way you will know which drugs will work best for you or not is to try them. They may not be the ones your doctor has prescribed. You need to treat the bg and the bp asap.
Another option, if it turns out the covered drugs don't work for you, is to have your doctor write a letter or medical necessity. I did that with novolog when my insurance no longer covered it and wanted to switch me to humalog. I got a free pack of humalog and tried it first and then when it didn't work out they covered novolog.You may be able to get free samples also.
Well, it seems to me that before you get as upset and critical as you are you should at least try what they will cover and see how it works.
Kind of hard to make an appeal that something won't work well enough until you've actually had it not work well enough.
I seen this in action. I used to take an SSRI for balance issues. The prescribed drug was a new, patent-valid and very expensive medication (can't remember what it was now, it's been years). Upon some research, I discovered that the new drug was simply a more purified form of the old drug -- turns out that when making it, two mirror isomers are produced ("left-hand" and "right-hand"), and only one of them was efficacious. The other isomer was biologically inert.
When the patent on the drug was running out, they developed a process to isolate the active isomer, created a new drug with it, patented it, and brought it to market.
Bottom line, you could take exactly the same active medication simply by dosing 2x on the old drug vs. the new drug. Went to my doctor and pointed this out, he looked into it a bit, and changed my prescription. Went from hundreds a month to something like $15 for the generic. It worked every bit as well, just at double the measured dose.