*UPDATE POST 69* Medication no longer covered on insurance formulary

[kerplop]

I will call DD's ped. and ask about this today. I've only ever found the generic Concerta at the pharmacies around here though. None stock the brand name. I guess I'd have to have it ordered and then use the coupon? Like you said, I wonder how often that could be done.

Speaking solely for the Vyvanse coupons, you can use them up to 12 times before you can no longer get the discount. Which means in a year I'll be SOL. I believe the free trial was 30 days, one use.

 

[dreiwhit]

My pharmacist said the insurance companies get a kick back and it's likely the Concerta manufacturer is giving them more.

I suspected it was something like that. The allergist / asthma specialist I see once told me why insurance would no longer cover the Veramyst nasal steriods I took (and worked) - he said it was because the drug manufacturer was no longer giving "kickbacks" to the insurance companies as an "incentive" to cover their drugs.

 

[LoveBWVVBR]

My pharmacist said the insurance companies get a kick back and it's likely the Concerta manufacturer is giving them more.

You guys were all correct. The insurance is covering the brand name Concerta, but not the generic. They say "Concerta brand now covered at preferred brand cost share". I have no idea what that means, as I don't know what the "preferred brand cost share" costs. Looks like I need to request for the pharmacy to order brand name Concerta now so we can get DD's prescription filled. So crazy that they're covering the brand not the generic now, but so many of you called that! Even weirder that the SAME company makes the brand and the generic. Why would they care which one the pharmacy promotes? They are both crazy expensive!!

ETA - Say the GoodRx cost on the Concerta brand is still cheaper. Would that also go through my insurance so it hits our deductable or no?

 

[FreeDiningFanatic]

From GoodRx website

Keep in mind though—the cost of prescriptions not purchased on your plan will not count toward your deductible. If you've had other medical expenses or if you have several pricey prescriptions, it may still be worth your while to use your insurance to satisfy your deductible.

 

[LoveBWVVBR]

From GoodRx website

Keep in mind though—the cost of prescriptions not purchased on your plan will not count toward your deductible. If you've had other medical expenses or if you have several pricey prescriptions, it may still be worth your while to use your insurance to satisfy your deductible.

Thank you. Not sure why I didn't see that on the FAQs when I read them. This is going to be something I have to weigh out. Not sure we'll hit our deductable this year, so it might make more sense to use the GoodRx pricing...not sure.

 

[Cars2006]

We just received information that our child's monthly medicine will no longer be covered on our insurance formulary. We were already paying over $180 a month for this (generic!) medicine. Going to another generic isn't possible as this particular medication had a host of generics disallowed as substitutes about 2 years ago. Those generics didn't work the same. Only the one our child takes works well. I can't imagine what it will cost without the insurance rate if it's $180 a month WITH the insurance rate. Also, without it being on the formulary, does that mean that we pay OOP and then it doesn't even go towards the deductable? We have a high deductable health plan, but in the past the $180+ a month went towards the deductable.

What choices do I have here? I'm guessing an appeal won't be possible. I'm don't even know if I can order it from Canada as it's technically controlled (ADHD med). Thank you for any guidance.

Our insurance just did the same with our sons adhd meds we went from 100.00 to 265.00 for a 1 month supply. They pay only pay 10.00. We have to do name brand because the generic did not work. Even with a pediatrician and autism doctors. They will not cover anymore of the co-pay. We use Cvs we also looked at Walmart, Target and Rite Aid and the difference is small between them all. He is on a couple of other medication for asthma and allergies so I cant wait to see how much they are going to be when we refill latet this month. I also called the company and waiting to hear back.

 

[soniam]

To the OP, I wish I could help. All I can do is send good vibes your way I used to take the brand version of an antidepressant. When I switched companies, I thought I had verified that they covered the brand, but they didn't. It was going to cost $1800/90 days versus $10/90 days for the generic. I, and my doctor, were a little reluctant. The generic increases the risk of seizures by 3 times. I did switch. It definitely felt different for a while, and I don't think it works quite as well. However, it seems to work well enough. I am always a little leery though.

 

[Mkid451]

Looks like I need to request for the pharmacy to order brand name Concerta now so we can get DD's prescription filled. So crazy that they're covering the brand not the generic now, but so many of you called that! Even weirder that the SAME company makes the brand and the generic. Why would they care which one the pharmacy promotes? They are both crazy expensive!!
?

If you switch to the concerta, explain the situation to the pharmacist. If they know this is something that you will be picking up every month, they will likely keep some in stock just for this situation. At my pharmacy we hate carrying extra inventory, but if we know that we have a patient that is going to be using a drug that we don't typically keep in stock on a regular basis, we will order it, and keep enough of it so they don't have to wait every month. Also, I'm not sure how it works everywhere, but I know when we order controlled substances, they take time to arrive. Most drugs we can get next day, and we have shipments that come in monday-friday. We only get a controlled substance twice a week, and it is more likely to get delayed due to the difference in how it is shipped to us. This could keep you waiting longer than you would like, so plan as far ahead as possible.

Again, they cover the brand and not the generic because the manufacturer is providing an incentive for the insurance company to do so.

Also, with GoodRx, take what you see on the website with a grain of salt. It might work perfectly, and that is awesome! But I've have a few coupons come in, and after running them through my system, they provided savings, but not nearly as much as they advertised on their website, and a few patients have taken that out on me (remember, the pharmacy staff doesn't decide what you pay!) If you wanted to, you could always bring in the GoodRx coupon, and have them bill to that. If that price is higher than what it would cost with insurance, you can always ask the pharmacy to rebill it through your insurance.

tl:dr Get to know your pharmacy's staff! They can really help you out, and are more willing to go over the top and past what is expected of them if they know you and you haven't treated them like absolute dirt!

 

[LoveBWVVBR]

Well, today was the day that I had to fill DD's prescription with the brand for the first time. I got a 90 day supply and I had to get it from Walgreens as it was the only pharmacy that had the brand in stock in my area. The insurance mailer had said that the cost share would likely be less...yeah right! So we went from paying $600 and change every three months to paying $849.xx!! They tried running Good RX but that brought it up to $925. It was crazy! I paid it because of course DD has to have this medicine, but this is nuts. Do I have any options? I'll try Costco because there is one in Orlando that I could go to, but we don't have one locally. Do I have to belong to use their pharmacy if it is less? There's really no way I can get this from Canada right?

The thing that kills me is that the pills are the SAME as the generic pills since the same manufacturer makes both. We just get to pay an extra $250 every three months for them now. UGH.

ETA - What if I got the prescription written so that they could fill with generic and then tried GoodRx on that? The GoodRx price looked a lot lower on the brand than the pharmacy quoted, but maybe it would be more accurate on the generic? UGH, I'll try anything at this point. This stinks.

 

[Jeff_G]

Yes see if your DR will write you another prescription for the generic and take it to the pharmacy with the good rx code. This will likely be cheaper then the name brand through insurance. It will just not count towards your deductible.

It is not legal to reimport ANY medication from Canada, I would not even think about trying this with a controlled substance.

 

[LoveBWVVBR]

Yes see if your DR will write you another prescription for the generic and take it to the pharmacy with the good rx code. This will likely be cheaper then the name brand through insurance. It will just not count towards your deductible.

It is not legal to reimport ANY medication from Canada, I would not even think about trying this with a controlled substance.

This is what I'm going to try next refill. I can't get over the cost...$849 for 3 months is insane to me.

 

[Teresa Pitman]

You don't have to belong to Costco to use the pharmacy (at least in Canada). I have been very pleased by how much cheaper the medications are at Costco.

 

[barkley]

you don't have to be a member of Costco in the u.s. to use their pharmacies as well.