Prescriptions and denials thereof....

jujube

jujube

SF VIP
Location
I think I'm in Florida, but I'm not sure any more.
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.
 
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...
 
Coco said:
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?
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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.
 
Flarbalard said:
@jujube -- if you don't mind, what drug was it? Just lookin' at Heloise's Eliquis paperwork, OMG :eek:, but it did drop about a grand, yes grand for 3 months.
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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
 
Sunkist said:
Does the pharmacist give you the option of getting a generic alternative instead?
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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.
 
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. :oops:

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.
 
Knight said:
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
Click to expand...
The State of N.J. uses OptumRX for our retiree Health Benefits Program. The most expensive medications, including Eliquis, cost me $28 for 90 day supplies. All of my glaucoma eye drops are $28. About half my prescriptions are $5 and under and half cost $28. It's astonishing to look at the claim forms and see how much those medications would cost without insurance. For Eliquis, it shows that my plan paid $718 this year (I had the prescription filled once this year).

Re the OP: My glaucoma specialist sent two different RXs for preservative free lubricating drops to two different pharmacies because she said insurance companies don't usually pay for them. One pharmacy was Blink Rx and they sent the Miebo drops free of charge. I'm sure if I reordered they wouldn't be free, but I won't because they make my vision blurry. I declined accepting the other RX when the pharmacy called.

I forgot the name of the pharmacy and drops but they were $195 with a special first time price of $59 for a month's supply.
I can't see paying $59 for a month of a lubricant drop then possibly $195 to refill. The doctor gave me a bottle of Ivizia, which I like so far, but I also found that Systane has preservative free drops, so I ordered that from Amazon. Two bottles for $19. I have used the original Systane Ultra for years and really liked it.
 
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