Prescriptions and denials thereof....

[jujube]

My doctor wants me to go on a medication. My Blue Cross pharmacy provider denied it. The doctor made an appeal, very eloquently. Blue Cross denied it again. I appealed it; they denied it a third time. The pharmacist said, well, let me see if we can get the manufacturer to help you with that, because they do quite often when it's too expensive (which it is). And then he said, oh, no, you have pharmacy insurance, so you can't get help from the manufacturer.

I said, well yeah but they denied it. Apparently that doesn't matter....as long as you have insurance, the manufacturer won't help you. So, if I didn't have insurance, they'd help me. But because I DO have insurance, even if they deny it and won't pay for it, the manufacturer won't help me. He did say he'd look for other programs that might help. Nothing so far.

That's the way it goes. They have what they call "affordable housing, etc" but you have to be too poor to actually afford the "affordable" rent. And you have pharmacy insurance but they won't pay for stuff.

Arrrgggghhhh!!!

Back to the drawing board.

 

[smiley]

where is all the true humanity in all of that??

 

[Coco]

Could you find out if the drug qualifies for the $2500 limit. I know youd have to pay out of pocket but but at least you could have it. It is totally unfair?

 

[Flarbalard]

Can your doctor get you some free samples from the manufacturer's rep?

 

[hollydolly]

You know when I read stories like this it makes me sooo mad !
I know our NHS leaves an enormous amount to be desired these days, but at least for the vast majority, if the doctor says we need a certain medication... then we get it..no-one stops it..and we get it for FREE!...

I wish you could come here Jujube, and get it prescribed for you here...

 

[MarciKS]

i know our pharmacy denies coverage on meds that are too expensive in an effort to force the hands of the makers to bring the price down to keep them from gouging us.

 

[Knight]

Have you checked the price & availability on
GoodRx.com

 

[Lizzie00]

Also Mark Cuban‘s Cost Plus Drugs…you can save a bundle if it’s something they carry.

 

[HoneyNut]

Back to the drawing board.

Have you tried asking AI (like Google 'ai mode' search)? When I googled about it there seem like additional steps a person can take, such as requesting an 'external review' or contacting the manufacturer directly, etc.

 

[Sunkist]

i know our pharmacy denies coverage on meds that are too expensive in an effort to force the hands of the makers to bring the price down to keep them from gouging us.

Does the pharmacist give you the option of getting a generic alternative instead?

 

[Aunt Bea]

Have you checked the price & availability on
GoodRx.com

Another vote for GoodRx or similar.

It won’t be as cheap as an insurance copay but it may bring it within reach.

Good luck!

 

[Sunkist]

Does the pharmacist give you the option of getting a generic alternative instead?

This ^ is a legitimate question..

 

[Aunt Bea]

I don’t know anything about Florida’s SHINE program but it might be worth a look.

SHINE - Home

 

[Murrmurr]

Try this website, Jujube...

https://crushcost.com

 

[Kaila]

Could you find out if the drug qualifies for the $2500 limit. I know youd have to pay out of pocket but but at least you could have it. It is totally unfair?

I think that limit,
only applies to a medicare part d plan, not a private like blue cross.

And in a part d plan, that limit is only for a drug the plan accepts, and not for any med that isn't included in their formulary list of meds covered.

 

[spookycat2]

GoodRx has helped me at times, to make the price reasonable enough that I can afford it.

 

[Flarbalard]

@jujube -- if you don't mind, what drug was it? Just lookin' at Heloise's Eliquis paperwork, OMG , but it did drop about a grand, yes grand for 3 months.

 

[Knight]

@jujube -- if you don't mind, what drug was it? Just lookin' at Heloise's Eliquis paperwork, OMG , but it did drop about a grand, yes grand for 3 months.

I think the price of prescriptions is outrageous. I'm glad I have a Medicare advantage plan & HSA. Needing a blood thinner ain't cheap.

A 100 day supply. Optum is mail order auto refill so they always give that 10 extra over a 90 day supply to make sure I never run out. I really like auto fill because they call my doctor ahead of time when refills are needed. I've never been less than 90 supply on hand.

OPTUM PHARMACY 701, LLC
ELIQUIS TAB 5MG
Claim processed - 02/19/2026
Claim #:
Date of visit: 02/19/2026
Total drug cost
Total drug cost $1,846.06
$1,846.06
Your share
Your share $345.00

 

[Lewkat]

One of my inhalers was just taken off my pharmacy coverage list. Another has been prescribed, but it is not good for one who has my type of heart condition. Fortunately, I rarely need it, so, I'll do without.

 

[MarciKS]

Does the pharmacist give you the option of getting a generic alternative instead?

I am so sorry. I didn't see this when you posted it.

So the Roflumilast I take for my lungs comes in an liquid form for a nebulizer but it's $1575 a month or something so it's an unapproved medicine on my insurance list. Reason being is if they deny it will help bring the cost down.

So instead I'm stuck with the pills that has more side effects.

Eventually if the price comes down I might switch.

 

[seadoug]

I just went in for my annual physical and my doctor had a few choice comments about the insurance companies. I'm with UHC, and oddly they recommend check-ups every 6 months for those on Medicare. I go for annual physicals, but this time I will go back in 6 months with no blood draw and just to chat with the doctor.

Re: prescriptions, I'm another member who has had good results with GoodRX. I pay $9.99 per month and two of my generic prescriptions are free. The third one costs $7.