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

 

[amcnj]

The only thing I recall happening was a prescription my mother had been taking was reclassified to a different level or tier, so that her co-payment for it was then higher. That was a few years ago. Hope the doctors can intercede and have you exempted.

 

[loves to dive]

Haven't tried it. I know years ago my mother's medications weren't covered and they were going to be something like $700 per month and there were two prescriptions like that. These weren't prescriptions that could be dropped so we ended up buying them on line from Canada. I don't think that option is legal any more (I'm talking over 15 years ago).

I currently take two prescriptions that did go up but not by much, maybe $2 each. However, my doctor's office got bought out by a big box doctor's organization and my first visit to them in Dec. went really bad. I left there looking for new doctor's but the only one's available within a 50 mile area that my insurance covers (Humana) were all big box. I only go to the doctor to get my prescriptions filled and to get my orders for my mamo. Since neither of my prescriptions are life saving (one for hormones since I had all my parts removed over 30 years ago and one for high triglycerides) I'm thinking of just going off both. It will be hell for hubby for a month or two and I've been told by a number of doctor's that I should never totally go off the hormones, but such is life. My last blood test about six months ago also showed high cholesterol but since I didn't want to go on statins, I've been taking a OTC recommended by my previous doc. The doc I refuse to go back to insisted both issues were life style even though I'm not overweight - not even close - at the time my tris went up I was actually close to underweight, ate no fat or artificial sugar and exercised 6 days a week. My previous doc. said given my personal history and my family history it was genetic. The doc I refuse to go back to didn't even ask about family or personal history, just assumed.

So, I shall roll the dice and take my chances on going off meds since I can't find a doctor. As far as the mamo goes, those are supposed to be given without a doctor referral and I have a history of issues but I think I'm probably just going to skip those as well. Again, the only place within 50 miles that gives them is the local hospital and let's just say the advice they gave me after my last one was shot down in 2 seconds flat by my doctor who knew me and my history. Don't you just love insurance and isn't it worth the money?

 

[LoveDaisy]

@loves to dive have you called you gynecologist to see if they will refill your prescriptions? My doctor retired and I’m currently doctor shopping. My gynecologist told me not to rush the process she can do my blood work and refill my thyroid medication. It might be an option for you.

 

[tvguy]

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

LOL. I looked at Medicare Advantage plans. Only my Primary Care Doctor is "In Network" I have health issues so the out of pocket with an Advantage plan would totally wipe out any prescripti8on savings. Not to mention having to wait for prior authorization. Waiting for open appointments with specialists is bad enough, adding a prior authorization delay would be a nighmare. However, my wife has a Humana Prescription plan and they do not cover this drug. She was curious and checked.

 

[Meriweather]

We have a Medicare advisor......so glad because it is very complicated. They do all the research every year and recommend the best part D plan to go with.
This year they had me change. The one I had last year no longer had one of my insulins in the formulary.
So I switched. That one doesn't use Express Scripts, but another mail order one called Optum RX. They covered all of the ones I need.
I just need to get my endocrinologist to send them the prescriptions.
They have never recommended Advantage.

 

[lanejudy]

If the exception is denied — or in the interim if you need a refill — check the manufacturer’s website for a patient assistance program. Many of the expensive brand-name meds offer some sort of savings card or program to reduce cost.

 

[Debbie Jean]

We have a Medicare advisor......so glad because it is very complicated. They do all the research every year and recommend the best part D plan to go with.
This year they had me change. The one I had last year no longer had one of my insulins in the formulary.
So I switched. That one doesn't use Express Scripts, but another mail order one called Optum RX. They covered all of the ones I need.
I just need to get my endocrinologist to send them the prescriptions.
They have never recommended Advantage.

I’ve had Optum RX for years. Their specialty pharmacy and home delivery have always been great.