Why do insurance companies do this???

[Terabith]

My kid has asthma.  She needs an inhaled corticosteroid to breathe.  The insurance company appears to enjoy changing which inhaled corticosteroid they will cover at random every 3-6 months.  So now, she ran out of refills on the one she was taking (and that works really well).  So I called the doctor's office, got them to call in a new prescription to the pharmacy, got the pharmacy to fill it, and was on my way to go pick it up when the pharmacy called and said, "Oh yeah, they changed and this one is no longer covered.  You need a prescription for this other one (that doesn't work nearly as well but not badly enough that we can get medical override)."  So I have called the nurse line.  They aren't supposed to talk to me since she's 18, but my anxious autistic just turned 18 year old cannot handle explaining to the nurse line that they need to call in a different one.  And there is no way for the pharmacy to fill it before they close at 6.  So we have air quality that is hazardous today; my kid can't breathe, and there's no way to get her inhaler today.  

These meds were invented in the 1950s.  Even with insurance they're insanely expensive.  Why???  And why do they change it every 6 months?  What purpose does that serve?

Edited July 17, 2023 by Terabith

[Drama Llama]

Flovent is the med my insurance company kept telling me we need to change my son to.  

I think the idea is that they just annoy you till you stop getting meds at all, and then  . . . 

Well then they'd have to pay for the hospital.  I'm not sure this is a well thought out plan on their part.

I am so sorry and not helpful.

[Bambam]

42 minutes ago, Terabith said:

My kid has asthma.  She needs an inhaled corticosteroid to breathe.  The insurance company appears to enjoy changing which inhaled corticosteroid they will cover at random every 3-6 months.  So now, she ran out of refills on the one she was taking (and that works really well).  So I called the doctor's office, got them to call in a new prescription to the pharmacy, got the pharmacy to fill it, and was on my way to go pick it up when the pharmacy called and said, "Oh yeah, they changed and this one is no longer covered.  You need a prescription for this other one (that doesn't work nearly as well but not badly enough that we can get medical override)."  So I have called the nurse line.  They aren't supposed to talk to me since she's 18, but my anxious autistic just turned 18 year old cannot handle explaining to the nurse line that they need to call in a different one.  And there is no way for the pharmacy to fill it before they close at 6.  So we have air quality that is hazardous today; my kid can't breathe, and there's no way to get her inhaler today.  

These meds were invented in the 1950s.  Even with insurance they're insanely expensive.  Why???  And why do they change it every 6 months?  What purpose does that serve?

I'm sorry. That stinks.

Something to think about the future - we usually ask how much the prescription is with insurance and without insurance. Sometimes (not often but often enough so it pays to ask), the prescription is cheaper without insurance. My DH is currently taking a medication that is about $30/month without insurance but much more with insurance. It makes my brain hurt. 

[Terabith]

1 minute ago, Bambam said:

I'm sorry. That stinks.

Something to think about the future - we usually ask how much the prescription is with insurance and without insurance. Sometimes (not often but often enough so it pays to ask), the prescription is cheaper without insurance. My DH is currently taking a medication that is about $30/month without insurance but much more with insurance. It makes my brain hurt. 

I asked.  It's $300 without insurance.  

[Katy]

Check Amazon & Walmart. When we had a kid with an inhaler it was hundreds through a chain pharmacy and $4 without insurance at Walmart. Had to stand in line an hour though. 

[Pawz4me]

Also check GoodRx and similar sites. 

[Terabith]

54 minutes ago, Katy said:

Check Amazon & Walmart. When we had a kid with an inhaler it was hundreds through a chain pharmacy and $4 without insurance at Walmart. Had to stand in line an hour though. 

Our insurance will not allow us to use a chain pharmacy.  We have to use the hospital pharmacy, since my husband is employed by the hospital.  Usually I like supporting the small, independent place, but it's also inconvenient, given the fact they are only open from 8:30 am till 6 pm.

[cintinative]

10 minutes ago, Terabith said:

Our insurance will not allow us to use a chain pharmacy.  We have to use the hospital pharmacy, since my husband is employed by the hospital.  Usually I like supporting the small, independent place, but it's also inconvenient, given the fact they are only open from 8:30 am till 6 pm.

I think they are suggesting to not run it through insurance and see how much the chain pharmacy costs.  I am so sorry that you are dealing with this. Somehow the fact this is insurance for a hospital makes it that much worse. Shaking my head. 

[kbutton]

1 hour ago, cintinative said:

Somehow the fact this is insurance for a hospital makes it that much worse. Shaking my head. 

Sad fact: Lots of healthcare systems and/or healthcare employers have the WORST insurance. We currently have some of our best insurance, but it's a new employer for DH. We are, however, cutting really close to the bone right now just from not being able to build up our HSA and such in years when we had lesser coverage. It's frustrating.

[Terabith]

Our insurance is mostly great.  And the hospital's insurance is not the only one that does this.  He's been employed by several different places over the years, and every single one has changed which inhaled corticosteroids they cover every six months like clockwork.  It's just deeply confusing.  

[rebcoola]

That is so weird we have medicore insurance but they never do that. They require ua to get it through their mail order pharmacy since its recurring though so that is its own annoyance.

[cintinative]

43 minutes ago, kbutton said:

Sad fact: Lots of healthcare systems and/or healthcare employers have the WORST insurance. We currently have some of our best insurance, but it's a new employer for DH. We are, however, cutting really close to the bone right now just from not being able to build up our HSA and such in years when we had lesser coverage. It's frustrating.

we are not employed by a hospital but I can totally relate to what you are saying.  I'm sorry.

[KidsHappen]

4 hours ago, Terabith said:

I asked.  It's $300 without insurance.  

Have you checked GoodRx. My pain meds were about $750 a month without insurance and not covered at all. With GoodRx it came down to $160 a month.

[TexasProud]

I second checking GoodRX.  It is free.  Sometimes we use that rather than our insurance because it is so much cheaper.  You can look online and it will show you the cost of your prescription.  The amount of difference was eye opening.  This makes no sense to me.  I am with you OP.  They should keep you on one and it should cost the same no matter where you go.  Changing is ridiculous!

[itsheresomewhere]

Check Walmart and GoodRx.  Walmart seems to be making medications affordable not using insurance.  We have had good luck using both and not using insurance to get some medication and making them affordable. 
 

Our plan using their idiotic doctor review just determined that the vitamin D test for DH is not a medical necessity ( I guess they have been under a rock and don’t realize what vitamin D is to the body).  I am appealing it but I have a feeling I will be stuck paying for it.  

[Spryte]

I’m so sorry. We might have the same insurance — we have the same issue with rotating covered asthma meds. 

Frustrating! I hope you get it sorted fast.
 

For us, our insurance adventure today: DS’s epipens are expired as of this month. We picked them up in Nov, and the expiration was less than a year. But insurance won’t cover refills until Nov. so we have to pay OOP. $180 with Good Rx. Ugh.

Edited July 18, 2023 by Spryte

[J-rap]

I'm sorry.  The health insurance industry is so frustrating.  

Sometimes a doctor can give you samples to tide you over, at no charge.

Can your dd authorize you to handle her health care needs easily?

We've used GoodRx occasionally too.

[mom31257]

I'm so sorry you are dealing with this!

I found this article that explains how middleman companies called pharmacy benefit managers are responsible for this, and it's about profit. This practice has been on the rise, too. There are some suggestions at the end of the article. 

https://www.consumerreports.org/prescription-drugs/when-your-insurer-drops-your-prescription-drug/

 

[Grace Hopper]

It won’t help immediately, but you should speak with your/her physician about submitting a prior authorization request to the insurance company to request that she stay on the same medication (and that they make a coverage exception). This is what we’ve done when there was a name brand drug that was much more effective than the generic for treatment I needed a while back. May not work but worth a try. 

[Mrs Tiggywinkle Again]

13 hours ago, kbutton said:

Sad fact: Lots of healthcare systems and/or healthcare employers have the WORST insurance. We currently have some of our best insurance, but it's a new employer for DH. We are, however, cutting really close to the bone right now just from not being able to build up our HSA and such in years when we had lesser coverage. It's frustrating.

Learning this myself.  I was sold on this new job by how awesome the insurance provided by the healthcare system is but it turns out—our commercial insurance through DH’s work was way better despite higher premiums and deductible.  I’m so over insurance.

[heartlikealion]

There is a list of certain meds that are affordable through Sam’s club. I don’t love their hours so don’t go there right now but worth looking into. You should not need to be a Sam’s member to use the pharmacy (or snack bar 🙂 ) 

[Tree Frog]

Riffing off of @heartlikealion's post, Costco also had reduced cost prescriptions. If you're a member, the cost is further reduced. They also do pet prescriptions. There is a federal law of some sort that requires Costco to offer non-members their pharmacy services. I expect it's the same for Sam's.

[Shelydon]

My inhaler is $350 with insurance, so I use goodrx and it is about $50 a month. 

[Heartstrings]

We use Good Rx for prescriptions and on top of the savings it’s liberating to not need to deal with insurance company. We have a couple of prescriptions that our insurance has denied covering but we can still get through Good Rx.  One prescriptions that we have is a daily pill that our insurance only covers 8 pills a month because reasons? 🤷‍♀️  Good Rx let’s us get the whole month.  

[Idalou]

Google Mark Cuban's prescription company. I have heard so many good things about it. Some meds are even less than those at Good rx. You just need a dr prescription sent to them, no insurance involved.

[OH_Homeschooler]

19 hours ago, BandH said:

Flovent is the med my insurance company kept telling me we need to change my son to.  

I think the idea is that they just annoy you till you stop getting meds at all, and then  . . . 

Well then they'd have to pay for the hospital.  I'm not sure this is a well thought out plan on their part.

I am so sorry and not helpful.

Not exactly the same thing, but I've been on continuous birth control for almost 10 years so I can avoid PMDD and wanting to kill myself every month. By some miracle I found a pill one that didn't make me crazy, and it was amazing. Then a few months ago the insurance company decided to switch me to something cheaper. Sure enough, it made me crazy like almost every other pill I've ever taken. I thought at my age (almost 50) I could just go off BC and be normal (hahaha). Nope.

It was definitely in my head that I was giving them what they wanted by just going off of birth control completely, so they wouldn't have to pay for it. I'm not a big conspiracist except when it comes to basically any kind of insurance coverage. 

I decided to go back on the good pill and just do self-pay. There is a savings card associated with this, which makes it affordable. Otherwise, there's no way I could pay for it every month. It might not seem like birth control is life or death but I think when it prevents you from wanting to kill yourself, it can be. But they never care or ask why you're taking a particular medication, just switch you randomly to save a penny.  

 

[heartlikealion]

2 hours ago, Tree Frog said:

Riffing off of @heartlikealion's post, Costco also had reduced cost prescriptions. If you're a member, the cost is further reduced. They also do pet prescriptions. There is a federal law of some sort that requires Costco to offer non-members their pharmacy services. I expect it's the same for Sam's.

I was a member at the time so that’s probably why it was so cheap. But might still be worth looking into these big box stores with or without a membership. Sam’s always has promotions for memberships. Costco is always full price it seems. I have a Costco membership at the moment, but not Sam’s. 

OP, you can go inside and ask for the printed list of reduced prices meds. 

[Kidlit]

Ditto on checking Costco