Anyone file for a prescription drug exemption?

[tvguy]

Anyone here file for an exemption from an insurance company decision to drop a medication from coverage?
I have private Medicare Part D coverage through Express Scripts. I got a letter saying a medication I am taking is no longer in their formulary effective January First. They suggested two alternatives. I went to the Cardiologist yesterday and showed him that letter. That caused a little controversy in his office as he gathered the two other Cardiologists there to show them. All three concurred, the two alternatives being suggested as not appropriate. My Cardiologist is contacted Express Scripts for clarification.
I can still get the medicine, and I have over two months supply on hand, but I have to pay full retail of over $800 for a 3 month supply. (And THAT is the GoodRX discount price) The big issue is, while Medicare Part D plans have a $2,500 a year cap on out of pocket, that ONLY applies to drugs in the formulary. So anything I pay for this drug, $3,200 a year, would not count against that. I am also exploring manufacturer coupons.

Any one have any luck with getting an exception?

 

[lanejudy]

I think it really depends on the plan. That’s why they have you confirm your meds during enrollment and recommend checking each year at open enrollment time. Good luck!

 

[Mathmagicland]

I can still get the medicine, and I have over two months supply on hand, but I have to pay full retail of over $800 for a 3 month supply. (And THAT is the GoodRX discount price) The big issue is, while Medicare Part D plans have a $2,500 a year cap on out of pocket, that ONLY applies to drugs in the formulary. So anything I pay for this drug, $3,200 a year, would not count against that. I am also exploring manufacturer coupons.

Maybe also price check Mark Cuban pharmacy? I’ve not used them but they are aiming to make meds more affordable.

https://www.markcubancostplusdrugcompany.com/

 

[georgina]

Anyone here file for an exemption from an insurance company decision to drop a medication from coverage?
I have private Medicare Part D coverage through Express Scripts. I got a letter saying a medication I am taking is no longer in their formulary effective January First. They suggested two alternatives. I went to the Cardiologist yesterday and showed him that letter. That caused a little controversy in his office as he gathered the two other Cardiologists there to show them. All three concurred, the two alternatives being suggested as not appropriate. My Cardiologist is contacted Express Scripts for clarification.
I can still get the medicine, and I have over two months supply on hand, but I have to pay full retail of over $800 for a 3 month supply. (And THAT is the GoodRX discount price) The big issue is, while Medicare Part D plans have a $2,500 a year cap on out of pocket, that ONLY applies to drugs in the formulary. So anything I pay for this drug, $3,200 a year, would not count against that. I am also exploring manufacturer coupons.

Any one have any luck with getting an exception?

Super bad that they waited until after Jan 1 to tell you. I made DH check that his part D plan for 2026 would still cover his prescription medications before the open enrollment period closed.

Those insurance companies can really suck. My sister had lung cancer surgery and was prescribed a drug to prevent recurrence. Her insurance co insisted she try a cheaper drug first, which gave her horrible intolerable side effects, before they would pay for the one that was prescribed.

 

[Dan Murphy]

Anyone here file for an exemption from an insurance company decision to drop a medication from coverage?
I have private Medicare Part D coverage through Express Scripts. I got a letter saying a medication I am taking is no longer in their formulary effective January First. They suggested two alternatives. I went to the Cardiologist yesterday and showed him that letter. That caused a little controversy in his office as he gathered the two other Cardiologists there to show them. All three concurred, the two alternatives being suggested as not appropriate. My Cardiologist is contacted Express Scripts for clarification.
I can still get the medicine, and I have over two months supply on hand, but I have to pay full retail of over $800 for a 3 month supply. (And THAT is the GoodRX discount price) The big issue is, while Medicare Part D plans have a $2,500 a year cap on out of pocket, that ONLY applies to drugs in the formulary. So anything I pay for this drug, $3,200 a year, would not count against that. I am also exploring manufacturer coupons.

Any one have any luck with getting an exception?

No help here, TV, but good luck, wishing you success.

 

[tvguy]

Super bad that they waited until after Jan 1 to tell you. I made DH check that his part D plan for 2026 would still cover his prescription medications before the open enrollment period closed.

Those insurance companies can really suck. My sister had lung cancer surgery and was prescribed a drug to prevent recurrence. Her insurance co insisted she try a cheaper drug first, which gave her horrible intolerable side effects, before they would pay for the one that was prescribed.

No, they did tell me before the Medicare deadline, I just assumed the alternatives they offered were reasonable. I even checked with a broker to see what my options were with drug coverage. The search came up with the plan I have, which covers 9 of the 10 medicines I take, and another that did cover the dropped medicine , but did not cover three other medicines, and was $40 a month more expensive.

 

[tvguy]

Maybe also price check Mark Cuban pharmacy? I’ve not used them but they are aiming to make meds more affordable.

https://www.markcubancostplusdrugcompany.com/

Thanks. Checked. Not on their list of drugs either. No generic available yet, could hit the market this year, or as late as 2031 due to legal challenges.

 

[Neapolitan Ice Cream]

The NHS pays for all my meds - I am chronically sick, and will remain so for years to come. As part of my monetary breaks, all my prescriptions are free.

 

[CdnCarrie]

The NHS pays for all my meds - I am chronically sick, and will remain so for years to come. As part of my monetary breaks, all my prescriptions are free.

Yup j just got all 6 of my refills and paid zero.

 

[disneychrista]

Yes and initially it was denied. But a few months later the prescription was filled without any issues. So either the decision was reversed or the medication was no longer not covered.

Insurance wanted me to try another medication first. But one of the major side effects is a slight increased risk for dementia and with family history neither me or my doctor thought that the benefit outweighed the risk.

 

[Mackenzie Click-Mickelson]

Did they give a reason for the drug no longer being covered? Expense, formula change beyond their limits, now needs special approval, etc?

What did your doctors say as for the reason the alternatives were not appropriate? Ineffectiveness, not workable for your specific condition, just a preference they use when others work as well, etc?

 

[tvguy]

Did they give a reason for the drug no longer being covered? Expense, formula change beyond their limits, now needs special approval, etc?

What did your doctors say as for the reason the alternatives were not appropriate? Ineffectiveness, not workable for your specific condition, just a preference they use when others work as well, etc?

No reason given for it being dropped.
The two drugs (which are in reality the same drug made by different companies) have a risk of thyroid and lung issues with long term use.
The drug I am taking is a much safer (milder) option. As the Doctor put it, he is expecting I will need to be on this medicine the rest of my life.

 

[slo]

I’m so sorry to hear this happened to you. I found out the other day that BC/BS IL decided to no longer cover my gel injections for my knees - not just for my plan, but all BC/BS plans - it really stinks (good thing I decided to replace my left knee this year). Doctors have no idea this is coming until either right before the new year or right after. The insurance companies don’t want to tell this info to early, because then people will rush to get things done or prescriptions filled. I think it’s a horrible thing to do to people, but they don’t care.

My suggestion is to start now into looking into which Medicare Advantage plan will cover your medication and get it set up for next year. If you decide to go this route, just make sure your doctors are in network with your plan. My mom has Humana and it covers some very very very expensive medication for her, but she had to find some new doctors, which stinks, but it’s more beneficial for the insurance to cover her medication than her doctors. She has found new doctors now and they are good doctors.

Good luck - I wish you well