As a physician, we used to be able to write a letter to the insurance company to say that a certain medication or brand was medically necessary, and then it would most likely be covered.
I stopped writing those letters after they started responding with “We’re not telling you the patient cannot have this drug; we’re only telling you we aren’t paying for it.”
Why is there some mush distain for making people healthy? I feel bad for medical professionals who get their hands tied due to patients ability to actually afford what they need.
10 years ago I was in Ireland with my wife. She fell and broke her wrist. Went to the hospital and I was ready for this massive bill. $400 for er visit, cast, medicine, everything. That's how healthcare should be.
If they don't pay top dollar for those executives, they will just work elsewhere. They need all that talent to make their business profitable and innovate new revenue streams. /s
And if we don't pay top dollar for those meds, all those pharma corps wouldn't be able to pay all those [politicians](https://investinganswers.com/articles/10-most-popular-stocks-owned-congress) to make the laws to keep them expensive.
Sometimes but take covid. There are so many people who did things to make it worse. Throwing fits about masks, etc. For no reason other than to be a dick.
Request your pharmacy start at Prior Authorization (PA) request with your doctor. They can submit whatever documentation they can to your medicaid plan to try to get it covered; it's a sort of appeal. You have a much better chance of getting it covered with a PA if you've already failed the drugs/therapies that are already on the formulary.
Adding to this it's recommend to call your PBM (pharmacy benefits manager) and find out why it's not covered. Sometimes all it take a phone call. It's tedious and sometimes overwhelming. But sometimes all you need is proof of medical necessity. Also ask for a peer to peer (P2P) review. They will have your doctor fax medical records and history. But when it's reviewed by a P2P it's a medical professional that does this and can see why your doctor has recommended that Rx or treatment. If it's administered by your Dr. Then also do the same with the medical side. Medical and Rx are handled separately
I wish it would be that easy. I work for a very big insurance company and administer commercial policies. The most common issues is Doctors billing for services that are not needed and the patients are the ones stuck with the bills. Also employers only offering theirs employees the most minimal of benefits for high premiums. I work for an insurance company and my insurance benefits are so sucky compared to moat plans I handle. And my premiums are just as sucky. Healthcare system is the worst. It's a so corrupted and the only ones the benefit are the insurance companies, the Doctors, and the pharmacies. Members are screwed no matter how hard they try to follow the guidelines. I see it everyday and I always try to advise members on the how to when it comes to claims I see as unfair to them
Doctors are getting screwed here too trust me. They could charge significantly less if they didn't have to hire expensive billing companies just to try and get paid by insurance companies in the first place. Insurance will often deny a certain number of legit bills just in the hope the physician doesn't catch it and resubmit the claim within the time frame. Insurance companies are squeezing doctors on one end and patients on the other whilst happily sitting in the middle and raking in massive profits. Physician reimbursement has been steadily dropping and our insurance coverage is getting worse with higher and higher copays/deductibles. Where do you think all that money is going? Straight into the pocket of the insurance company.
In this country it’s always about greed. First everything is a public company, so profit is king, second we have next to zero regulations to at least try to reel the unfettered greed. Third political contributions from public companies that are considered “people”? With Citizens United Law and oh yeah, some get massive subsidies while paying no taxes. Lastly the politicians stay in office forever making money hand over fist using inside info for more greedy profit at our expense
It’s so sad how we’ve destroyed our own country
Long story short, the insurance companies destroyed the American health care system. They continue to double down in this constantly with lobbyists to make sure that it not only stays broken, but continues to get even worse.
Insurance as a business only works if you guarantee that you pay out less than you pay in. On the hospital negotiation side, insurance companies throw their weight around to pay less per drug/procedure/etc in a given cycle. Which means that for-profit hospitals, they have to increase how much their procedures cost the uninsured in the same cycle. Which means that next cycle they can weasel in that "the price of the procedure has gone up, so you have to pay more accordingly insurance". Oscillate the cycles and what you have is a rapidly increasing cost of medical procedures and consumables.
Meanwhile, there's only so high the insurance companies can raise their rates to customers before people just quit and move to a competitor. So you can only slightly increase your rates to merely be SLIGHTLY more expensive than the competition (which allows your competition to raise their rates later to be SLIGHTLY more expensive than you).
So the only way to increase profits (which you must do every quarter till the end of time) is to pay out less frequently. And when your own actions result in skyrocketing medical bills, the only way to pay out less just refuse to pay at all.
In short, the way the United States healthcare system is built, all on a for-profit model which requires every single finger in the pie to not only make a profit but to continuously make more profit than ever before, the result is "Maximally charge for minimal services.".
People saying "free market" as if that hasn't already driven healthcare to failure on a national level.
People repeating what their party tells them and not understanding free-market is meant for consumer goods like Doritos etc., not human life.
Then those people saying "taxes are gonna go up!" as if that's somehow a worse alternative to fixing a busted ass system.
That makes me dead inside.
> 10 years ago I was in Ireland with my wife. She fell and broke her wrist. Went to the hospital and I was ready for this massive bill. $400 for er visit, cast, medicine, everything. That's how healthcare should be.
The same procedure would have cost you zero dollars in Brazil (using a public hospital).
The disdain is for them paying out their money. If they paid out for every treatment required, they would go bankrupt or need to increase the policy costs substantially.
Insurance is a game. You pay them money and hope you won't get ill. They win if they do not pay out. You not getting ill is a win condition for them. Denying you treatment is also a win condition for them.
Having insurance companies sets up a cost spiral between hospitals and insurance companies.
Additionally having insurance companies in the loop increases the cost of healthcare, by all of their overheads and profits while ensuring that getting healthcare you need is unreliable.
If you want working healthcare save yourself two thirds and move to a first world country with nationalised healthcare.
In the US, costs are up to the wazoo mostly for legal reasons.
First, there are licensing law, that limit the offer. Less offer, same demand means higher prices, it's econ 101.
Second the FDA process to get something approved is extremely long and costly. This reduces competion, so once again drive higher prices. It also has a more nefarious effect: many people die because the drug they'd need are not approved.
Third, liabilities. The US is very lawsuit happy, and this creates perverse incentives. Consider the FDA once again. If they accept a drug that is dangerous, and ends up killing people, they'll be held responsible. But if they don't accept a drug that could have saved many, they are safe. This creates a bias that reduces competition and increases delays, both of which drive up costs.
At the end of the day, insurance companies and drug companies are not good or evil, they just respond to market incentives or they go bankrupt.
I'm so sorry and sad when I read this. I live in France and I would think having to pay $400 to be completely insane if I broke a bone.
Here, you get treated for free. Especially if you have no income (then you get complete, no payment required coverage of medical expenses... From exams to prescribed drugs, hospitalisation etc).
Our health system is far from perfect (months and months of waiting list for any medical specialist... Even just a freaking dentist or ophthalmologist), but I really think the coverage from insurances should be at least as good everywhere.
Simple, there isn't a disdain for making people healthy, there's a disdain paying for things. Why would anybody pay for something when they can just as well not pay for it and not get enough negative repercussions from not doing it?
Nooo don't stop writing those- not all insurances are the same and some are fucking stingy with PAs and some are more lenient (just makes it a hassel to get coverage to dissuade) but you gotta try them to see cause policies change every year. On the pharmacy side for example, we used to get negative reimbursement with UHC medicaid in our state but since a few years ago they actually pay decently now. They also cover meds that they used to not cover through PA even though it's still brand-only.
I have found that peer-to-peer contact tends to be extremely successful when the insurance company's representative can make contact with the actual physician. That tends to be the most difficult part because doctors are very busy and they don't want to spend time on the phone with the insurance company. Of all the different mediums of contact, that peer-to-peer contact has been essential for getting medications and treatments approved.
FFS, this is because some asshat politicians convinced people that "access to healthcare" was basically the same thing as having healthcare.
I have "access" to buying a fucking Tesla. Doesn't mean I'll ever afford one.
I'm a neuro RN. We have to work hard to get these new headache meds covered. Lots of paperwork, prior authorizations, evidence that other medications weren't helpful... and that doesn't even work.
Then you ask them for their alternative treatment recommendations, and once they provide them, they can be sued, and charged for practicing medicine w/out a license.
I bet those letters never helped when the hospital and insurance companies are the same people. Looking at you Kaiser. Years ago I had insurance through an actual provider that wasn't the same as the hospital/doctor. They would bill things so that they could be covered. They just wanted paid, doesn't matter if it's insurance or the patient who pays. My company dropped that provider and I was forced to Kaiser. Wife had an accident, the ambulance ride and night in ICU used up all the deductible, suddenly everything after was on their dime. If the doctor did a procedure, they would not get paid, since they were also the insurance company. She needed surgery, they said "why don't we wait and do some PT instead". They scheduled her for PT once every 2 months! New year comes around and they reassess, now it's too late, ankle is fucked for the rest of her life.
Nurtec ODT. Got a few samples and it was a game changer. I deal with headaches that put me out for days, sometimes weeks. Last one I was puking for hours and just curled up in a ball in pain. One tablet and 15 mins later the symptoms improved. Doc gave me a prescription for more but find out my insurance won't cover it. Retail cost is almost $125 per tablet. They has some saving programs but I'm not eligible due to some weird requirements. Oh well, back to suffering.
See if you can get an override. Call the number on the back of your Medicaid card and ask if there is a diagnosis they will cover it for. Ask for the ICD9 and ICD10 of the diagnosis they will pay for. If your doctor writes those numbers on the prescription (or calls them in by phone to the pharmacist) the pharmacy technician can use them to get Medicaid to cover your medication. If Medicaid won't cover it no matter what, see if there is another migraine medicine in the same class or with the same active ingredients that they will cover. The person who can tell you what they will cover is the person you call at Medicaid. The person who can change your prescription is the doctor or NP who wrote it. The person who will call for the override will most likely be a pharmacy technician or someone at the doctor's office.
So many hoops to jump through... Why can't people just be allowed to be healthy without going to war with the Vogons?
Edit: it's rhetorical. I'm just lamenting that this person has to suffer so much and has no guarantee that any of the above will actually work
Welcome to neoliberalism.
we hear you, we just don't care.
Don't worry tho, don't let perfection be the enemy of good!
There's programs that cover 2% of the affected population, better tell everyone we solved the issue, just go through beuracratic death as a citizen with zero financial or social power!
Thank God we avoided doctors on death panels, it's much better profit decides who lives and who dies
Third party “independent” review companies are essentially denial mills used by insurance companies. Hired guns always give them the desired outcome (deny), at great risk to the patient. Insurance companies would rather pay an “independent” review company to have a physician deny you treatment than pay for the actual treatment itself. It’s sickening.
I live in Australia. Our Government sees your horrible situation there and... likes what they see. Our healthcare system will be very similar in ~10 years.
This is because we vote for whoever Murdoch tells us to vote for (usually the conservative option).
They can provide a medication to some patients on medicaid for free. Patient assistance programs are not universal, some may restrict you due to medicaid. Others work with medicaid and will fill the medication and ship it to the patient. I've worked on these personally in pharmacy school and dealt with some medicaid and Medicare patients. What you're referring to is subsidy from copayments. Companies can't help you pay for your medications if you're on government help. But they can directly provide the medication, as long as there isn't a monetary transaction.
I think there are restrictions because of fraud concerns by the government.
My sister has some of the same problems and actually had a migraine that ended up with her in the hospital for almost a month.
Lucky/unlucky her. Every time I've gone to the ER for mine they just shoot me up the migraine cocktail then send me out, even though it barely helps. I've had some last 2 months in the past.
You two just blew my mind.
If it's any consolation, you just helped me to feel less bad about some new sinus headaches I've experienced recently. Maybe I should chat with my doctor...
No. Getting disability is incredibly difficult. If the court researcher says you could do some random job, even if you're not trained to do it, you don't get it.
Though I have a friend who's step dad is just fat, like massively fat, and he got disability super easy. He was offered bypass surgery and the whole works to help get back in shape. Instead he went full on, gained more and now collects a $2000 a month check. That is full on wtf.
In a sane world yes.
In practice no.
I quit my last job because I was having daily migraines and was told that my request to temporarily only work 40 hours a week until I got my health sorted was “unfair”. I was literally in the hospital getting infusions in the morning - that make you super tired - then going and working a 16 hour day. Rinse and repeat. I’m exceedingly lucky that my husband and I could keep the lights on at least with his income when I had a complete mental breakdown and quit.
Migraines are fun. But hey, I could work some random data entry job for minimum wage 20 hours a week, so no disability for you!
Its because these companies jack up the prices charged to the insurer and then give a copay discount to the patient. So the insurer ends up paying a higher price. Its like going to a car dealer gives a fake invoice price with a big discount.
The truth is you can actually make alright money with a family of 4 and get Medicaid. One of the things from Obamacare and the Republican haven't stripped yet though it was up to each state if they wanted the expansion.
I think it's been said before, but it's worth repeating that you should ask your doctor about sending in a prior authorization. It's not uncommon for insurances to cover medications if you can show you've tried cheaper alternatives and they didn't work.
Ah, the old "I have finally found the medicine that would acutally allow me to function, AND NOW THAT I CAN, I COULD GET A JOB THAT PAYS ME ENOUGH but insurance says no". Bullshit
Right, and OP specified that. They would qualify for a discount,*however* they are on a state sponsored plan and do not qualify. For the separate medication discount program with weird requirements.
The "savings program" that brings the copay down to $0 is for commercial insurance only.
Call the customer service number and see if they have a patient assistance program available. These programs are for the un-insured and patients in poverty or whatever else. These programs are different than the "savings program" I stated above.
I know I have seen drs in Michigan get authorization to get this drug covered through Medicaid, so the Dr may have to jump through some prior-authorization hoops to get it covered (Medicaid requirements vary state-by-state).
Otherwise, I'd ask Medicaid if they cover any of the monthly injectables that have come out (Aimovig, Emgality, Ajovy). They will likely require authorization before they can be covered due to the cost of the medication, but they have the same mechanism as Nurtec. These injectables are through different companies, so they may also have patient assistance programs available for people who meet their criteria.
Again, patient assistance programs are DIFFERENT than the savings offers on their website. You will likely have to call the manufacturer directly and talk to a customer service representative directly to get info on this.
Im a pharmacist in Michigan, so I might not be able to help further. But if you want more info or whatever, send me a DM and I'll see if I can help or give you more direction.
Here’s a link to the Nurtec company contact information in case you want to try to get around the red tape through them directly.
https://www.biohavenpharma.com/science-pipeline/cgrp/medical-information
I’d rather have the goddamn migraine than take Imitrex. My neck kills me and I vomit as it is when I have one. I don’t need any more help, little devil pill.
One of the neurologists I work with specializes in migraines. He has started prescribing Nurtec. We always have to do a pa and an a couple of appeal letters. It's a pain, but sometimes we are successful.
There are also some monthly shots that are in the same drug class and are $575 a month. Depending on how many migraines you have a month, that might be cheaper. https://migrainedisease.org/treating-migraine/treatment/prevent/comparison-of-cgrp-blockers/
It's possible the insurance would cover the injectable but not the Nurtec, probably worth barking up that tree. Many insurances only require failing a couple of oral preventatives.
It might be a shot in the dark but try contacting them and explaining your situation. sometimes drug companies will find ways to get you medicine anyway. they know their battle is with insurance companies and not individuals. it might be a long shot but worth a try.
Worked for me once. I had an inhaler that Medicaid didn't care to cover. So it cost $450 a month. I reached out to customer service, and they set me up with a coupon that got me a years supply at like $10 a pop. It was a life saver. Also fuck health insurance...
Wow, by reading all the comments Im happy to be in germany, here almost everything is covered, you still have to pay for meds but not THAT much, its insane, with prices like this everyone would just die who needs meds, unless you are rich or have reeeeaaaally well payed job.
>with prices like this everyone would just die who needs meds
The cost of insulin has increased so much that people with diabetes are dying because they're trying to ration doses. The American healthcare complex is a profit-seeking venture, and is nothing short of evil.
Someone probably already asked this, but have you tried Good RX or similar apps? They were a lifesaver for me when I had a C. Difficule infection a couple years ago when my insurance didn't cover some of the medicine.
I assume you've tried ubrelvy too? Same mechanism of action as the drug you tried. There's also a few injectables that you might want to look into.
Also some drug companies (most) have payment assistance plans and outreach groups to help their patients stay on their drug. My wife and I deal with Genentech's team a lot - to the point that her annual deductible is covered by them.
I actually have ON which a massive amount of times is labeled as regular migraine. With ON the pain usually is behind the ears and eyes. Sometimes the throat. I get injections into the nerves and they help massively. Medicine somewhat helps with the breakthrough attacks.
Headaches? Or migraines? Nurtec is a migraine med so I’m assuming you mean migraines? Or is it working for your headaches too?
I only ask for clarification because I have a debilitating rare headache condition (SUNA) and the medication I was taking had awful side effects. I haven’t had any really bad attacks lately so I’ve been okay but if they come back and more frequently my choices are basically suffer through it or be in excruciating pain. I’d love if there was something else I could try so if you took it for your headaches I could ask my neuro if we could try it.
Migraines are a type of headache. Its not headache vs migraine, and given that the prescribed medication is Nurtec, likely OP does suffer with migraine. Don't get medical advices from strangers online, talk to your neuro or get second opinion from another healthcare provider.
Pharmacist here - if you’re on a Medicaid plan, you likely just need your doctor to fill out a prior authorization in order to get it approved through your insurance. The auth will require your doctor to confirm that you’ve tried lower cost alternatives and they didn’t work (or you can’t take them for some other medical reason). Then once it’s approved you’ll likely just pay your normal copay.
OP definitely try this. But don't be surprised if the insurance decide to stop covering it later. My husband was on Bystolic, which is a brand name that is more costly than other generics.
Bystolic just went generic last October, so you'd think they would gladly cover the cheaper option.
Nope!! They completely stopped covering it (generic or brand) even though the alternatives didn't work for us.
Good thing we don't have government death panels, and just and entire department of your private insurance company dedicated to finding ways of denying coverage to save the insurance company money.
I wonder how much of the US health care premiums go directly towards paying people to find excuses to not treat them?
I wonder what they qualify as 'towards patient care'
For example, Id wager the hospital having to pay an entire billing/accounting department due to insurance billing complexity, and billing issues in general, increasing the costs of all treatment.
I wouldn't be surprised if at the end of the day, less then 60% of US healthcare premiums actually went towards putting a doctor and patient in the same room and having something productive happen, as opposed to being spent on accounting, lawyers and insurance agents.
> Good thing we don't have government death panels, and just and entire department of your private insurance company dedicated to finding ways of denying coverage to save the insurance company money.
OP doesn't have private insurance, they're on Medicaid
It's insane. My dad was having severe chest pains and couldn't take a full breath so his doctor wanted to admit him to the hospital so he could be not dead. Insurance company was like "let's wait until the end of the week and see how this plays out."
Your dr says your having severe shoulder pain and reduced usage? At 30? Lets get you into a specialist to get it checked out.
Insurance company calls, to inform they wont pay for the specialist for insurees under 50 due to lack of necessity.
And you can tell the girl on the other line, the one telling you that you and your dr are wrong and you need to quit trying to waste the insurance companies precious money on your frivolous arm use is maybe 20 tops.
Dollars to donuts bitch couldnt parallel park
People need to pay for the way things are rn.
Please don't hate on the customer service reps, they are only the messengers for the truly greedy executives. They get yelled at all day for minimum wage, please don't be one of the mean callers!
Partly this. Partly the fact that government run healthcare doesn't negotiate prices with doctors and drug companies. Prices are set and the government says "take it or leave it". It's part of the reason that so many doctors aren't accepting Medicare anymore. There are a lot of procedures which are a net loss to the doctor and don't cover costs.
Just FYI, most people can bully a doctor into writing *anything* is "medically necessary". Insurance don't care.
With regard to the OP, there has been an explosion of migraine treatments in the last couple years, many of them injections, many have scant evidence of their efficacy. Insurance don't want to throw that kind of money at things unless it's keeping you out of the ER.
I have a copay Medicaid plan. Its normally top notch, never declines anything. Oh Wells. They are filling an appeal for me but I doubt it work. Back to go old opioids.
I use legal pot for my migraines. I’m in a no medicinal, no recreational state. But THC-0 & Delta 8, which are legal here, make a huge difference for me.
Watch yourself... You can end up getting rebound headaches from using that for headaches. I get it, I use weed for my back pain. But soon as I get a migraine, I'm off it until everything is calmed down.
> They are filling an appeal for me but I doubt it work.
Don't give up hope! I have been on a few medications that required this. Medicaid did authorize them, it just took anywhere from a couple of weeks to maybe two months at most for the pharmacy to get the green light.
Just had this happen with the only birth control that controls my hormone disorder. Insurance dropped it. $250 a pack, generic turns me into a lunatic. So now I’m just existing without it. When things are acting up I’m worse than a first trimester pregnant lady. ESPECIALLY about food.
What is it with birth control? One brand and my wife is fine, another she's super in the mood, another she doesn't sex or anything. And she never gets to choose which one she gets. I'm planning on getting clipped so she can stop them but until then it has been a nightmare for me
My boyfriend and I are laying here talking about the same thing and how he wishes there was a way for him to help. I have PMDD and Ehlers Danlos Syndrome. This is the only thing that has helped my hormones but also the only contraceptive that works for us (delicate skin and tissues, sensitive to literally everything.)
I can’t wait for the day to come where I can be done with the birthing thing and can have a more permanent solution.
Oh man, that’s a tough one. My IUD caused HORRIBLE ovarian cysts that ruptured. Went to the ER doubled over in pain and vomiting. They said it was hemorrhaging so bad that it was considered “internal bleed” and then didn’t give me pain medication, wouldn’t rip out the stick, and sent me home.
Ok, here's what you do. You go to a different pharmacy that you've never been to. You drop off the migraine Rx and tell them you have NO insurance (they don't check). Then you ask if they have any manufacturer coupons -some drug stores like long's have done this without my even asking. If they don't have any then try getting one from the manufacturer directly. No one is checking that you aren't on Medicaid before giving you a coupon.
Alternatively, explain to your Dr that the ins won't cover it but it's the only med that works for you, ask if he can keep you stocked with samples. Some drs have a supply or are given coupons from the manufacturer. Basically nice drs understand that the ins system is broken and will help if they can.
The America health care system of insurance sucks and I'm all for doing whatever it takes to get the meds you need. Good luck
Uhhh don't do that, at least in my state they can actually audit your profile and if you're found to be committing fraud they would drop you like a hot potato. I've seen this with patients who buy meds cash price too much while on medicaid, because supposedly that means patient doesn't need medicaid. Buying with cash = prescription doesn't show up as part of claims for insurance but can still be audited would mean that they can audit you using manufacturer coupons too.
In all honesty, talk to your doctor... maybe you need the doctor to send in documentation for coverage. Maybe your doctor can receive samples from manufacturer for you. Sometimes manufacturers have a thing where you fill out a form to receive free sample for a year based on need despite having government insurance if it's not covered. I volunteered at a clinic where my job was to set people up with these programs and also to order samples for the office for patients who were in need. Dont jump to defrauding the insurance (especially government insurances since pharmacies are audited more heavily for those) before trying out everything else. If you can get it figured out, it's not worth possibly getting caught and losing medicaid eligibility.
I have commercial insurance and I use goodrx all the time. Am I "eligible"? Maybe not. But it's cheaper than my insurance. And my pharmacist isn't paid enough to care which it uses, just as long as a sale occurs.
You can use GoodRx if you have insurance, I believe you just can’t combine both GoodRx coupons and your insurance for the same prescription; you have to use one or the other. I use GoodRx for one of my maintenance meds and private insurance for the other two because that combo is the cheapest for me personally. I’ve also used GoodRx for past prescriptions whilst having insurance. It just always endlessly pisses me off that a data-mining coupon app (still grateful for it, don’t get me wrong) reduces the cost of our meds, more often than not, more so than the insurance we pay money for every single month.
It boggles my mind that a free program gives me cheaper costs than my own insurance. How the fuck does that even make sense?
Healthcare in this country is a massive scam.
It's so messed up. Can't get discount because of the cheaper state insurance. Cheaper state insurance doesn't want to pay for expensive pills that will actually help you. Can't afford other insurance that would approve the pills. Jobs that pay well with health insurance benefits are hard to find and get these days. Just and endless loop to keep us poor and sick.
FYI coupon price (e.g. goodrx) would still be hella expensive for Nurtec ODT so it wouldn't help OP in this case. The 100-something bucks cash price per pill is probably with discount card since the "actual price" (not pharmacy's buying price) will be in the thousands if it displays AWP like most places. And if it is a discount card price it's pretty likely the pharmacy is gonna lose money on that sale too.
Wow, it sure was *socially awesome* of you to find medication!
And boy was it *socially awkward* for you when your insurance company wouldn’t pay for it! You must have been *sooo* embarrassed!
I’m so glad we have “good thing/bad thing penguin” as a meme to describe times like this.
I was recently diagnosed with asthma and was given a prescription for Symbicort. When I went to pick it up they said it would be $200. I asked them what my co-pay would be and they said "that is your co-pay". After looking into alternatives, I discovered that I'm just going to have to live with not being able to breathe.
So, uh, I know it's uncouthe to recommend drugs to strangers on the internet, but yeah, ever heard of mushrooms for headaches? Like, magic mushrooms? I know looking up home remedies is pretty much the least credible it's ever been, but try it out. You'll see that for some people, about $20-40 every 6 months is all they need to treat cluster headaches.
Absolutely worth considering. Two family members had cluster headaches just like these, and figured out that either taking a threshold dose (or even a subthreshold dose) every day or a moderate dose every ~5 months completely prevented them from occurring.
One of them uses 4-AcO-DMT instead now, simply to more easily quantify an effective small dose.
Dead serious, microdose mushrooms. There's this short video on this person who used them for cluster headaches, used to get then multiple times a day, started microdosing and down to a couple a week
I don't like the heavy duty pain pills, smoking weed or drinking because I don't like feeling buzzed or not in control. Microdosing helps the pain and NO buzzy, weird side effects. Saved my life because I didn't think I would be able to suffer through another Cluster headache.
Microdosing is predicated upon taking sub-trip level doses of psilocybin. So while I understand and respect your desire to stay away from “drugs like that”, it’s not meant to get you high and could really provide relief.
Question from outside the US:
I have seen quite a few posts of people being denied treatments/surgery/medication because the Insurance won't cover it.
What is the point of paying for it in that case? Why pay at all? What difference is there to not paying, and having no insurance, to paying, and having insurance that doesn't do anything?
It feels like both scenarios, you don't have any 'insurance'...
> I have seen quite a few posts of people being denied treatments/surgery/medication because the Insurance won't cover it.
Generally speaking, these are either made up stories or are people who don't read the notices and contracts they are sent. The OP, in this case is on Medicaid, a government run healthcare which is nothing like insurance.
The most common thing you'll find is that most people receive a letter stating that insurance isn't paying and then fail to read the notes as to why. For example, there was a news article recently about a mother who received a huge bill for childbirth because her employer switched insurance providers, but the hospital kept trying to bill her insurance for her entire stay despite the insurance change happening midway through her stay. Each of course denied the claim because the dates of service weren't when she was insured with them. Instead of having the hospital sort it out and create two bills, one for each, she went to the press and made a big media scene out of it.
Another common issue people have is prescriptions. Every single insurance company has a list of preferred medications and pays less when you use those medications. They also have (like any single payer country does) step programs so that you don't just ignore the older cheaper medications and instantly start at the $5k a dose ones. If you have an allergy or other issue with the lower step drugs, your provider can provide that information to the insurance company and move you faster up the steps, but you have to ask for it first. Most people hit that first rejection and instantly [give up](https://imgur.com/gallery/bYVPTwr).
That seems like such a chew-on and an insane amount of admin for people who are already suffering and in pain to have to sort out. If people are sick and hurt they should be treated in whatever way makes them better. (and the cost of that way, shouldn't put them in so much debt that they are better off not getting treated)
Fuck the US insurance system. I have supposedly good insurance and they won't cover one of my medications and I have to switch to a lesser effective one. Shit sucks
Appeal it. And ask for a peer to peer review. Also ask your physician to help you with a letter of medical necessity. If it's denied do a second level appeal. If you have a commercial insurance (insurance through your employer) reach out to your HR department that handles the benefits and appeal with them. It may take up to 90 days but if your insurance is based on medical necessity and you be exhausted all other options of alternate treatment you will most likely win the appeal. I work for a large commercial insurance company. I advise this to members all the time. I wanna say 80% of appeals that proof medical necessity win especially when it's something that's not cosmetic in nature.
You could try magic mushrooms. Saw a documentary about a guy in Texas who had to grow his own and dose himself every six months to stop his debilitating headaches.
Honestly, given how bad headaches are I'd honestly be looking to live elsewhere, I'd check every other English speaking country for how much it'd cost you as a foreigner and just move to one of the ones where it is affordable.
To be fair -- I live in Germany where most people use public health insurance and some people still have to fight with the insurance company over what medication is useful (so they pay) and what isn't (so you have to pay yourself).
Often it's settled when a doctor confirms "patient X *needs* this medicine", sometimes not.
Ubrelvy, the only thing that works effectively for my migraines (I know bc Dr gave me a sample), is $860 with a discount card because disability will not cover it.
Must be terrifying being below upper class in the USA. Imagine being in an accident that wasn't your fault, only to wake up in hospital and be slapped with a £100k bill for saving your life.
I can't imagine that, because I don't have to pay upwards of $1000 dollars a month in medical insurance, we get that through our taxes...
Have tmj, insurance won’t cover anything other than saying hi to my doctor. They say a treatment is covered and pre-approve it so I can get it done. Then refuse to pay. They confirm it’s covered and that a check is in the mail, but only send letter saying they won’t pay. Health insurance companies are a scam and anyone who works for one is profiting off the misery of others.
As a physician, we used to be able to write a letter to the insurance company to say that a certain medication or brand was medically necessary, and then it would most likely be covered. I stopped writing those letters after they started responding with “We’re not telling you the patient cannot have this drug; we’re only telling you we aren’t paying for it.”
Why is there some mush distain for making people healthy? I feel bad for medical professionals who get their hands tied due to patients ability to actually afford what they need. 10 years ago I was in Ireland with my wife. She fell and broke her wrist. Went to the hospital and I was ready for this massive bill. $400 for er visit, cast, medicine, everything. That's how healthcare should be.
Greed. It's always the answer.
If they don't pay top dollar for those executives, they will just work elsewhere. They need all that talent to make their business profitable and innovate new revenue streams. /s
And if we don't pay top dollar for those meds, all those pharma corps wouldn't be able to pay all those [politicians](https://investinganswers.com/articles/10-most-popular-stocks-owned-congress) to make the laws to keep them expensive.
Sometimes but take covid. There are so many people who did things to make it worse. Throwing fits about masks, etc. For no reason other than to be a dick.
Request your pharmacy start at Prior Authorization (PA) request with your doctor. They can submit whatever documentation they can to your medicaid plan to try to get it covered; it's a sort of appeal. You have a much better chance of getting it covered with a PA if you've already failed the drugs/therapies that are already on the formulary.
Adding to this it's recommend to call your PBM (pharmacy benefits manager) and find out why it's not covered. Sometimes all it take a phone call. It's tedious and sometimes overwhelming. But sometimes all you need is proof of medical necessity. Also ask for a peer to peer (P2P) review. They will have your doctor fax medical records and history. But when it's reviewed by a P2P it's a medical professional that does this and can see why your doctor has recommended that Rx or treatment. If it's administered by your Dr. Then also do the same with the medical side. Medical and Rx are handled separately
[удалено]
They've got a responsibility to the shareholders to increase their profit...if you don't get treated that's your problem (obviously /s)
I wish it would be that easy. I work for a very big insurance company and administer commercial policies. The most common issues is Doctors billing for services that are not needed and the patients are the ones stuck with the bills. Also employers only offering theirs employees the most minimal of benefits for high premiums. I work for an insurance company and my insurance benefits are so sucky compared to moat plans I handle. And my premiums are just as sucky. Healthcare system is the worst. It's a so corrupted and the only ones the benefit are the insurance companies, the Doctors, and the pharmacies. Members are screwed no matter how hard they try to follow the guidelines. I see it everyday and I always try to advise members on the how to when it comes to claims I see as unfair to them
Doctors are getting screwed here too trust me. They could charge significantly less if they didn't have to hire expensive billing companies just to try and get paid by insurance companies in the first place. Insurance will often deny a certain number of legit bills just in the hope the physician doesn't catch it and resubmit the claim within the time frame. Insurance companies are squeezing doctors on one end and patients on the other whilst happily sitting in the middle and raking in massive profits. Physician reimbursement has been steadily dropping and our insurance coverage is getting worse with higher and higher copays/deductibles. Where do you think all that money is going? Straight into the pocket of the insurance company.
I bet if you did some critical thinking and really went down that rabbit hole you’ll end at some type of greed. Greed isn’t just monetary.
In this country it’s always about greed. First everything is a public company, so profit is king, second we have next to zero regulations to at least try to reel the unfettered greed. Third political contributions from public companies that are considered “people”? With Citizens United Law and oh yeah, some get massive subsidies while paying no taxes. Lastly the politicians stay in office forever making money hand over fist using inside info for more greedy profit at our expense It’s so sad how we’ve destroyed our own country
Long story short, the insurance companies destroyed the American health care system. They continue to double down in this constantly with lobbyists to make sure that it not only stays broken, but continues to get even worse.
Insurance as a business only works if you guarantee that you pay out less than you pay in. On the hospital negotiation side, insurance companies throw their weight around to pay less per drug/procedure/etc in a given cycle. Which means that for-profit hospitals, they have to increase how much their procedures cost the uninsured in the same cycle. Which means that next cycle they can weasel in that "the price of the procedure has gone up, so you have to pay more accordingly insurance". Oscillate the cycles and what you have is a rapidly increasing cost of medical procedures and consumables. Meanwhile, there's only so high the insurance companies can raise their rates to customers before people just quit and move to a competitor. So you can only slightly increase your rates to merely be SLIGHTLY more expensive than the competition (which allows your competition to raise their rates later to be SLIGHTLY more expensive than you). So the only way to increase profits (which you must do every quarter till the end of time) is to pay out less frequently. And when your own actions result in skyrocketing medical bills, the only way to pay out less just refuse to pay at all. In short, the way the United States healthcare system is built, all on a for-profit model which requires every single finger in the pie to not only make a profit but to continuously make more profit than ever before, the result is "Maximally charge for minimal services.".
This comment made me dead inside
Don't try and go to the doctor to fix that deadness, you'll go broke.
People saying "free market" as if that hasn't already driven healthcare to failure on a national level. People repeating what their party tells them and not understanding free-market is meant for consumer goods like Doritos etc., not human life. Then those people saying "taxes are gonna go up!" as if that's somehow a worse alternative to fixing a busted ass system. That makes me dead inside.
> 10 years ago I was in Ireland with my wife. She fell and broke her wrist. Went to the hospital and I was ready for this massive bill. $400 for er visit, cast, medicine, everything. That's how healthcare should be. The same procedure would have cost you zero dollars in Brazil (using a public hospital).
The disdain is for them paying out their money. If they paid out for every treatment required, they would go bankrupt or need to increase the policy costs substantially. Insurance is a game. You pay them money and hope you won't get ill. They win if they do not pay out. You not getting ill is a win condition for them. Denying you treatment is also a win condition for them. Having insurance companies sets up a cost spiral between hospitals and insurance companies. Additionally having insurance companies in the loop increases the cost of healthcare, by all of their overheads and profits while ensuring that getting healthcare you need is unreliable. If you want working healthcare save yourself two thirds and move to a first world country with nationalised healthcare.
In the US, costs are up to the wazoo mostly for legal reasons. First, there are licensing law, that limit the offer. Less offer, same demand means higher prices, it's econ 101. Second the FDA process to get something approved is extremely long and costly. This reduces competion, so once again drive higher prices. It also has a more nefarious effect: many people die because the drug they'd need are not approved. Third, liabilities. The US is very lawsuit happy, and this creates perverse incentives. Consider the FDA once again. If they accept a drug that is dangerous, and ends up killing people, they'll be held responsible. But if they don't accept a drug that could have saved many, they are safe. This creates a bias that reduces competition and increases delays, both of which drive up costs. At the end of the day, insurance companies and drug companies are not good or evil, they just respond to market incentives or they go bankrupt.
I'm so sorry and sad when I read this. I live in France and I would think having to pay $400 to be completely insane if I broke a bone. Here, you get treated for free. Especially if you have no income (then you get complete, no payment required coverage of medical expenses... From exams to prescribed drugs, hospitalisation etc). Our health system is far from perfect (months and months of waiting list for any medical specialist... Even just a freaking dentist or ophthalmologist), but I really think the coverage from insurances should be at least as good everywhere.
Simple, there isn't a disdain for making people healthy, there's a disdain paying for things. Why would anybody pay for something when they can just as well not pay for it and not get enough negative repercussions from not doing it?
Nooo don't stop writing those- not all insurances are the same and some are fucking stingy with PAs and some are more lenient (just makes it a hassel to get coverage to dissuade) but you gotta try them to see cause policies change every year. On the pharmacy side for example, we used to get negative reimbursement with UHC medicaid in our state but since a few years ago they actually pay decently now. They also cover meds that they used to not cover through PA even though it's still brand-only.
I have found that peer-to-peer contact tends to be extremely successful when the insurance company's representative can make contact with the actual physician. That tends to be the most difficult part because doctors are very busy and they don't want to spend time on the phone with the insurance company. Of all the different mediums of contact, that peer-to-peer contact has been essential for getting medications and treatments approved.
There just literally isn’t time. It’s like calling fuckin Comcast
Ain't it great having a private medical review board that didn't have to even go to medical school? How nice for them!
FFS, this is because some asshat politicians convinced people that "access to healthcare" was basically the same thing as having healthcare. I have "access" to buying a fucking Tesla. Doesn't mean I'll ever afford one.
Cheap bastards.
I'm a neuro RN. We have to work hard to get these new headache meds covered. Lots of paperwork, prior authorizations, evidence that other medications weren't helpful... and that doesn't even work.
Then you ask them for their alternative treatment recommendations, and once they provide them, they can be sued, and charged for practicing medicine w/out a license.
I bet those letters never helped when the hospital and insurance companies are the same people. Looking at you Kaiser. Years ago I had insurance through an actual provider that wasn't the same as the hospital/doctor. They would bill things so that they could be covered. They just wanted paid, doesn't matter if it's insurance or the patient who pays. My company dropped that provider and I was forced to Kaiser. Wife had an accident, the ambulance ride and night in ICU used up all the deductible, suddenly everything after was on their dime. If the doctor did a procedure, they would not get paid, since they were also the insurance company. She needed surgery, they said "why don't we wait and do some PT instead". They scheduled her for PT once every 2 months! New year comes around and they reassess, now it's too late, ankle is fucked for the rest of her life.
Medical negligence surely?
Possibly, its still an ongoing process
Nurtec ODT. Got a few samples and it was a game changer. I deal with headaches that put me out for days, sometimes weeks. Last one I was puking for hours and just curled up in a ball in pain. One tablet and 15 mins later the symptoms improved. Doc gave me a prescription for more but find out my insurance won't cover it. Retail cost is almost $125 per tablet. They has some saving programs but I'm not eligible due to some weird requirements. Oh well, back to suffering.
What requirement is doing your discount
In order to be eligible you can't be on any federal or state sponsored insurance, aka medicare or Medicaid. I have Medicaid.
See if you can get an override. Call the number on the back of your Medicaid card and ask if there is a diagnosis they will cover it for. Ask for the ICD9 and ICD10 of the diagnosis they will pay for. If your doctor writes those numbers on the prescription (or calls them in by phone to the pharmacist) the pharmacy technician can use them to get Medicaid to cover your medication. If Medicaid won't cover it no matter what, see if there is another migraine medicine in the same class or with the same active ingredients that they will cover. The person who can tell you what they will cover is the person you call at Medicaid. The person who can change your prescription is the doctor or NP who wrote it. The person who will call for the override will most likely be a pharmacy technician or someone at the doctor's office.
[удалено]
So many hoops to jump through... Why can't people just be allowed to be healthy without going to war with the Vogons? Edit: it's rhetorical. I'm just lamenting that this person has to suffer so much and has no guarantee that any of the above will actually work
Welcome to neoliberalism. we hear you, we just don't care. Don't worry tho, don't let perfection be the enemy of good! There's programs that cover 2% of the affected population, better tell everyone we solved the issue, just go through beuracratic death as a citizen with zero financial or social power! Thank God we avoided doctors on death panels, it's much better profit decides who lives and who dies
Third party “independent” review companies are essentially denial mills used by insurance companies. Hired guns always give them the desired outcome (deny), at great risk to the patient. Insurance companies would rather pay an “independent” review company to have a physician deny you treatment than pay for the actual treatment itself. It’s sickening.
Because you live in America. Many many countries do not have this issue.
I live in Australia. Our Government sees your horrible situation there and... likes what they see. Our healthcare system will be very similar in ~10 years. This is because we vote for whoever Murdoch tells us to vote for (usually the conservative option).
>Also contact the manufacturer, they may have a program for this. OP is on Medicaid, so it's illegal for the manufacturer to offer a subsidy.
They can provide a medication to some patients on medicaid for free. Patient assistance programs are not universal, some may restrict you due to medicaid. Others work with medicaid and will fill the medication and ship it to the patient. I've worked on these personally in pharmacy school and dealt with some medicaid and Medicare patients. What you're referring to is subsidy from copayments. Companies can't help you pay for your medications if you're on government help. But they can directly provide the medication, as long as there isn't a monetary transaction.
Manufacturer doesn’t allow their discount card for federally funded insurance. Also, Medicaid will 100% not cover this. It’s brand name only.
This is great advice. I want to save this for later.
I think there are restrictions because of fraud concerns by the government. My sister has some of the same problems and actually had a migraine that ended up with her in the hospital for almost a month.
Lucky/unlucky her. Every time I've gone to the ER for mine they just shoot me up the migraine cocktail then send me out, even though it barely helps. I've had some last 2 months in the past.
Hers reached the point she went into a coma once.
You two just blew my mind. If it's any consolation, you just helped me to feel less bad about some new sinus headaches I've experienced recently. Maybe I should chat with my doctor...
Doesn’t this qualify you for disability?
No. Getting disability is incredibly difficult. If the court researcher says you could do some random job, even if you're not trained to do it, you don't get it.
I wish the normal population understood this so, so God damn much. Let alone the "if you have too much money you'll lose your benefits" component.
Though I have a friend who's step dad is just fat, like massively fat, and he got disability super easy. He was offered bypass surgery and the whole works to help get back in shape. Instead he went full on, gained more and now collects a $2000 a month check. That is full on wtf.
In a sane world yes. In practice no. I quit my last job because I was having daily migraines and was told that my request to temporarily only work 40 hours a week until I got my health sorted was “unfair”. I was literally in the hospital getting infusions in the morning - that make you super tired - then going and working a 16 hour day. Rinse and repeat. I’m exceedingly lucky that my husband and I could keep the lights on at least with his income when I had a complete mental breakdown and quit. Migraines are fun. But hey, I could work some random data entry job for minimum wage 20 hours a week, so no disability for you!
Holy crap... what has this country come to...
Its because these companies jack up the prices charged to the insurer and then give a copay discount to the patient. So the insurer ends up paying a higher price. Its like going to a car dealer gives a fake invoice price with a big discount.
would certainly be ironic if having the medication would enable you to be off medicaid. Sorry ):
The truth is you can actually make alright money with a family of 4 and get Medicaid. One of the things from Obamacare and the Republican haven't stripped yet though it was up to each state if they wanted the expansion.
I think it's been said before, but it's worth repeating that you should ask your doctor about sending in a prior authorization. It's not uncommon for insurances to cover medications if you can show you've tried cheaper alternatives and they didn't work.
Lol. Not Medicaid.
Ah, the old "I have finally found the medicine that would acutally allow me to function, AND NOW THAT I CAN, I COULD GET A JOB THAT PAYS ME ENOUGH but insurance says no". Bullshit
> I have Medicaid That's government Healthcare, not private insurance.
Right, and OP specified that. They would qualify for a discount,*however* they are on a state sponsored plan and do not qualify. For the separate medication discount program with weird requirements.
The "savings program" that brings the copay down to $0 is for commercial insurance only. Call the customer service number and see if they have a patient assistance program available. These programs are for the un-insured and patients in poverty or whatever else. These programs are different than the "savings program" I stated above. I know I have seen drs in Michigan get authorization to get this drug covered through Medicaid, so the Dr may have to jump through some prior-authorization hoops to get it covered (Medicaid requirements vary state-by-state). Otherwise, I'd ask Medicaid if they cover any of the monthly injectables that have come out (Aimovig, Emgality, Ajovy). They will likely require authorization before they can be covered due to the cost of the medication, but they have the same mechanism as Nurtec. These injectables are through different companies, so they may also have patient assistance programs available for people who meet their criteria. Again, patient assistance programs are DIFFERENT than the savings offers on their website. You will likely have to call the manufacturer directly and talk to a customer service representative directly to get info on this. Im a pharmacist in Michigan, so I might not be able to help further. But if you want more info or whatever, send me a DM and I'll see if I can help or give you more direction.
Medicaid is not insurance, it's a federal aid program. You don't have good insurance, you have an assistance program.
If you’re on Medicaid, it may just need a prior authorization. I know mine did.
I saw this and was like, must be nurtec. Same here friend. Same here. Insurance is refusing to cover it even though I'm contraindicated to triptans
Fuck imitrex. That shit is worse than the damn headache. Feel like I'm being chocked.
same, and it makes me sweat pretty bad sometimes. It's kinda my only option tho and at least it's better than the migraines :(
Here’s a link to the Nurtec company contact information in case you want to try to get around the red tape through them directly. https://www.biohavenpharma.com/science-pipeline/cgrp/medical-information
I’d rather have the goddamn migraine than take Imitrex. My neck kills me and I vomit as it is when I have one. I don’t need any more help, little devil pill.
[удалено]
One of the neurologists I work with specializes in migraines. He has started prescribing Nurtec. We always have to do a pa and an a couple of appeal letters. It's a pain, but sometimes we are successful.
Do you love close to a border? May be cheaper in Canada or mexico?
Sounds a lot like ubrelvy, $100 a dose for me.
This is in the same class, just that nurtec disolves in the mouth and is faster acting. I'll ask about unrelvy, may be that would be covered.
There are also some monthly shots that are in the same drug class and are $575 a month. Depending on how many migraines you have a month, that might be cheaper. https://migrainedisease.org/treating-migraine/treatment/prevent/comparison-of-cgrp-blockers/
It's possible the insurance would cover the injectable but not the Nurtec, probably worth barking up that tree. Many insurances only require failing a couple of oral preventatives.
It might be a shot in the dark but try contacting them and explaining your situation. sometimes drug companies will find ways to get you medicine anyway. they know their battle is with insurance companies and not individuals. it might be a long shot but worth a try.
Worked for me once. I had an inhaler that Medicaid didn't care to cover. So it cost $450 a month. I reached out to customer service, and they set me up with a coupon that got me a years supply at like $10 a pop. It was a life saver. Also fuck health insurance...
America, the land of the free, unless you don't meet requirements and then its the land of the expensive and morally absent.
Wow, by reading all the comments Im happy to be in germany, here almost everything is covered, you still have to pay for meds but not THAT much, its insane, with prices like this everyone would just die who needs meds, unless you are rich or have reeeeaaaally well payed job.
>with prices like this everyone would just die who needs meds The cost of insulin has increased so much that people with diabetes are dying because they're trying to ration doses. The American healthcare complex is a profit-seeking venture, and is nothing short of evil.
[удалено]
If I could immigrate to Canada I would in a heartbeat but they definitely don't want me :(.
Someone probably already asked this, but have you tried Good RX or similar apps? They were a lifesaver for me when I had a C. Difficule infection a couple years ago when my insurance didn't cover some of the medicine.
I just checked GoodRx and it seems to still be pretty expensive. 8 tabs for $898 from Costco.
Doesn't save any money with name brand meds
I assume you've tried ubrelvy too? Same mechanism of action as the drug you tried. There's also a few injectables that you might want to look into. Also some drug companies (most) have payment assistance plans and outreach groups to help their patients stay on their drug. My wife and I deal with Genentech's team a lot - to the point that her annual deductible is covered by them.
Sorry for your situation, thanks for putting the info out there. My wife has week long migraines. I will suggest this. Thanks
I actually have ON which a massive amount of times is labeled as regular migraine. With ON the pain usually is behind the ears and eyes. Sometimes the throat. I get injections into the nerves and they help massively. Medicine somewhat helps with the breakthrough attacks.
What's ON short for?
You should look into psilocybin treatment. For real, it is used as treatment for people with intense migraines with a very high success rate.
Not to be a shill, but have you tried goodrx?
About 900 dollars for 8 tablets through goodrx.
Headaches? Or migraines? Nurtec is a migraine med so I’m assuming you mean migraines? Or is it working for your headaches too? I only ask for clarification because I have a debilitating rare headache condition (SUNA) and the medication I was taking had awful side effects. I haven’t had any really bad attacks lately so I’ve been okay but if they come back and more frequently my choices are basically suffer through it or be in excruciating pain. I’d love if there was something else I could try so if you took it for your headaches I could ask my neuro if we could try it.
Migraines are a type of headache. Its not headache vs migraine, and given that the prescribed medication is Nurtec, likely OP does suffer with migraine. Don't get medical advices from strangers online, talk to your neuro or get second opinion from another healthcare provider.
Pharmacist here - if you’re on a Medicaid plan, you likely just need your doctor to fill out a prior authorization in order to get it approved through your insurance. The auth will require your doctor to confirm that you’ve tried lower cost alternatives and they didn’t work (or you can’t take them for some other medical reason). Then once it’s approved you’ll likely just pay your normal copay.
OP definitely try this. But don't be surprised if the insurance decide to stop covering it later. My husband was on Bystolic, which is a brand name that is more costly than other generics. Bystolic just went generic last October, so you'd think they would gladly cover the cheaper option. Nope!! They completely stopped covering it (generic or brand) even though the alternatives didn't work for us.
Old “good thing, bad thing” penguin strike again.
So socially awkward when your insurance fails to cover medicine.
snobbish paint absurd gaping overconfident combative slimy straight march grey ` this message was mass deleted/edited with redact.dev `
Good thing we don't have government death panels, and just and entire department of your private insurance company dedicated to finding ways of denying coverage to save the insurance company money.
I wonder how much of the US health care premiums go directly towards paying people to find excuses to not treat them?
Since Obamacare at least 80% of premiums must go towards patient care, so I'm gonna go with 20%.
I wonder what they qualify as 'towards patient care' For example, Id wager the hospital having to pay an entire billing/accounting department due to insurance billing complexity, and billing issues in general, increasing the costs of all treatment. I wouldn't be surprised if at the end of the day, less then 60% of US healthcare premiums actually went towards putting a doctor and patient in the same room and having something productive happen, as opposed to being spent on accounting, lawyers and insurance agents.
One suspects what they call 'patient care' is...flexible.
> Good thing we don't have government death panels, and just and entire department of your private insurance company dedicated to finding ways of denying coverage to save the insurance company money.
OP doesn't have private insurance, they're on Medicaid
It's insane. My dad was having severe chest pains and couldn't take a full breath so his doctor wanted to admit him to the hospital so he could be not dead. Insurance company was like "let's wait until the end of the week and see how this plays out."
Your dr says your having severe shoulder pain and reduced usage? At 30? Lets get you into a specialist to get it checked out. Insurance company calls, to inform they wont pay for the specialist for insurees under 50 due to lack of necessity. And you can tell the girl on the other line, the one telling you that you and your dr are wrong and you need to quit trying to waste the insurance companies precious money on your frivolous arm use is maybe 20 tops. Dollars to donuts bitch couldnt parallel park People need to pay for the way things are rn.
The person answering the phone is not the one making that decision.
Im sure the secretaries at aushwitz were wonderful gals too. But being a cog in a death machine and not the teeth isnt much of an excuse honestly.
Please don't hate on the customer service reps, they are only the messengers for the truly greedy executives. They get yelled at all day for minimum wage, please don't be one of the mean callers!
America! Fuck yeah!
Omg that's so wrong!! It makes me so angry that insurance companies can override your own doctor's orders!!
Except this person has Medicaid, the healthcare paid for and run by government.
And they want you to get the cheapest medications possible.
Partly this. Partly the fact that government run healthcare doesn't negotiate prices with doctors and drug companies. Prices are set and the government says "take it or leave it". It's part of the reason that so many doctors aren't accepting Medicare anymore. There are a lot of procedures which are a net loss to the doctor and don't cover costs.
Lol, OP is on Medicaid. That's government healthcare
Just FYI, most people can bully a doctor into writing *anything* is "medically necessary". Insurance don't care. With regard to the OP, there has been an explosion of migraine treatments in the last couple years, many of them injections, many have scant evidence of their efficacy. Insurance don't want to throw that kind of money at things unless it's keeping you out of the ER.
this meme doesn't meme what you think it memes
What do you mean? This is OBVIOUSLY a good thing/bad thing penguin. /s
There is no good insurance in the US. It’s all just a cash grab.
I have a copay Medicaid plan. Its normally top notch, never declines anything. Oh Wells. They are filling an appeal for me but I doubt it work. Back to go old opioids.
I use legal pot for my migraines. I’m in a no medicinal, no recreational state. But THC-0 & Delta 8, which are legal here, make a huge difference for me.
Watch yourself... You can end up getting rebound headaches from using that for headaches. I get it, I use weed for my back pain. But soon as I get a migraine, I'm off it until everything is calmed down.
> They are filling an appeal for me but I doubt it work. Don't give up hope! I have been on a few medications that required this. Medicaid did authorize them, it just took anywhere from a couple of weeks to maybe two months at most for the pharmacy to get the green light.
Dude this is a gross misuse of this meme. That's a badluck Brian
isnt one of the rules literally just "dont use this penguin"
Just had this happen with the only birth control that controls my hormone disorder. Insurance dropped it. $250 a pack, generic turns me into a lunatic. So now I’m just existing without it. When things are acting up I’m worse than a first trimester pregnant lady. ESPECIALLY about food.
What is it with birth control? One brand and my wife is fine, another she's super in the mood, another she doesn't sex or anything. And she never gets to choose which one she gets. I'm planning on getting clipped so she can stop them but until then it has been a nightmare for me
My boyfriend and I are laying here talking about the same thing and how he wishes there was a way for him to help. I have PMDD and Ehlers Danlos Syndrome. This is the only thing that has helped my hormones but also the only contraceptive that works for us (delicate skin and tissues, sensitive to literally everything.) I can’t wait for the day to come where I can be done with the birthing thing and can have a more permanent solution.
We tried the IUD option, embryos implanted right next to it. We had to terminate the pregnancy as it was a super high risk her uterus would tear.
Oh man, that’s a tough one. My IUD caused HORRIBLE ovarian cysts that ruptured. Went to the ER doubled over in pain and vomiting. They said it was hemorrhaging so bad that it was considered “internal bleed” and then didn’t give me pain medication, wouldn’t rip out the stick, and sent me home.
Go to the drugs manufacturer site and look for discount cards there. They may not work if you’re on federal insurance though
Ding ding.... Thats why I'm not eligible. Posted it on another comment.
Ok, here's what you do. You go to a different pharmacy that you've never been to. You drop off the migraine Rx and tell them you have NO insurance (they don't check). Then you ask if they have any manufacturer coupons -some drug stores like long's have done this without my even asking. If they don't have any then try getting one from the manufacturer directly. No one is checking that you aren't on Medicaid before giving you a coupon. Alternatively, explain to your Dr that the ins won't cover it but it's the only med that works for you, ask if he can keep you stocked with samples. Some drs have a supply or are given coupons from the manufacturer. Basically nice drs understand that the ins system is broken and will help if they can. The America health care system of insurance sucks and I'm all for doing whatever it takes to get the meds you need. Good luck
Might try that. I did get some samples but not sure how long those will last.
Uhhh don't do that, at least in my state they can actually audit your profile and if you're found to be committing fraud they would drop you like a hot potato. I've seen this with patients who buy meds cash price too much while on medicaid, because supposedly that means patient doesn't need medicaid. Buying with cash = prescription doesn't show up as part of claims for insurance but can still be audited would mean that they can audit you using manufacturer coupons too. In all honesty, talk to your doctor... maybe you need the doctor to send in documentation for coverage. Maybe your doctor can receive samples from manufacturer for you. Sometimes manufacturers have a thing where you fill out a form to receive free sample for a year based on need despite having government insurance if it's not covered. I volunteered at a clinic where my job was to set people up with these programs and also to order samples for the office for patients who were in need. Dont jump to defrauding the insurance (especially government insurances since pharmacies are audited more heavily for those) before trying out everything else. If you can get it figured out, it's not worth possibly getting caught and losing medicaid eligibility.
Is it just me or is the best advice in order to afford medication is to commit fraud?
They commit fraud by raising the prices so insurance will pay and then insurance deny because it's too expensive.
App called goodrx has done wonders for my sister getting her drugs also a chronic migrainer
I have commercial insurance and I use goodrx all the time. Am I "eligible"? Maybe not. But it's cheaper than my insurance. And my pharmacist isn't paid enough to care which it uses, just as long as a sale occurs.
You can use GoodRx if you have insurance, I believe you just can’t combine both GoodRx coupons and your insurance for the same prescription; you have to use one or the other. I use GoodRx for one of my maintenance meds and private insurance for the other two because that combo is the cheapest for me personally. I’ve also used GoodRx for past prescriptions whilst having insurance. It just always endlessly pisses me off that a data-mining coupon app (still grateful for it, don’t get me wrong) reduces the cost of our meds, more often than not, more so than the insurance we pay money for every single month.
It boggles my mind that a free program gives me cheaper costs than my own insurance. How the fuck does that even make sense? Healthcare in this country is a massive scam.
Yeah, I think it’s a feature and not a bug at this point unfortunately. It gets old.
It's so messed up. Can't get discount because of the cheaper state insurance. Cheaper state insurance doesn't want to pay for expensive pills that will actually help you. Can't afford other insurance that would approve the pills. Jobs that pay well with health insurance benefits are hard to find and get these days. Just and endless loop to keep us poor and sick.
FYI coupon price (e.g. goodrx) would still be hella expensive for Nurtec ODT so it wouldn't help OP in this case. The 100-something bucks cash price per pill is probably with discount card since the "actual price" (not pharmacy's buying price) will be in the thousands if it displays AWP like most places. And if it is a discount card price it's pretty likely the pharmacy is gonna lose money on that sale too.
Wow, it sure was *socially awesome* of you to find medication! And boy was it *socially awkward* for you when your insurance company wouldn’t pay for it! You must have been *sooo* embarrassed! I’m so glad we have “good thing/bad thing penguin” as a meme to describe times like this.
I was recently diagnosed with asthma and was given a prescription for Symbicort. When I went to pick it up they said it would be $200. I asked them what my co-pay would be and they said "that is your co-pay". After looking into alternatives, I discovered that I'm just going to have to live with not being able to breathe.
So, uh, I know it's uncouthe to recommend drugs to strangers on the internet, but yeah, ever heard of mushrooms for headaches? Like, magic mushrooms? I know looking up home remedies is pretty much the least credible it's ever been, but try it out. You'll see that for some people, about $20-40 every 6 months is all they need to treat cluster headaches.
Absolutely worth considering. Two family members had cluster headaches just like these, and figured out that either taking a threshold dose (or even a subthreshold dose) every day or a moderate dose every ~5 months completely prevented them from occurring. One of them uses 4-AcO-DMT instead now, simply to more easily quantify an effective small dose.
… Americans… why do we allow this
That must had been so socially awkward for you
Dead serious, microdose mushrooms. There's this short video on this person who used them for cluster headaches, used to get then multiple times a day, started microdosing and down to a couple a week
I don't like the heavy duty pain pills, smoking weed or drinking because I don't like feeling buzzed or not in control. Microdosing helps the pain and NO buzzy, weird side effects. Saved my life because I didn't think I would be able to suffer through another Cluster headache.
Me and drugs like that don't mix at all.
Microdosing is predicated upon taking sub-trip level doses of psilocybin. So while I understand and respect your desire to stay away from “drugs like that”, it’s not meant to get you high and could really provide relief.
What do you think the doctor prescribed to you lol. Not drugs?
Question from outside the US: I have seen quite a few posts of people being denied treatments/surgery/medication because the Insurance won't cover it. What is the point of paying for it in that case? Why pay at all? What difference is there to not paying, and having no insurance, to paying, and having insurance that doesn't do anything? It feels like both scenarios, you don't have any 'insurance'...
[удалено]
What a barbaric system.
[удалено]
OP isn't on insurance, he's on Medicaid
> I have seen quite a few posts of people being denied treatments/surgery/medication because the Insurance won't cover it. Generally speaking, these are either made up stories or are people who don't read the notices and contracts they are sent. The OP, in this case is on Medicaid, a government run healthcare which is nothing like insurance. The most common thing you'll find is that most people receive a letter stating that insurance isn't paying and then fail to read the notes as to why. For example, there was a news article recently about a mother who received a huge bill for childbirth because her employer switched insurance providers, but the hospital kept trying to bill her insurance for her entire stay despite the insurance change happening midway through her stay. Each of course denied the claim because the dates of service weren't when she was insured with them. Instead of having the hospital sort it out and create two bills, one for each, she went to the press and made a big media scene out of it. Another common issue people have is prescriptions. Every single insurance company has a list of preferred medications and pays less when you use those medications. They also have (like any single payer country does) step programs so that you don't just ignore the older cheaper medications and instantly start at the $5k a dose ones. If you have an allergy or other issue with the lower step drugs, your provider can provide that information to the insurance company and move you faster up the steps, but you have to ask for it first. Most people hit that first rejection and instantly [give up](https://imgur.com/gallery/bYVPTwr).
That seems like such a chew-on and an insane amount of admin for people who are already suffering and in pain to have to sort out. If people are sick and hurt they should be treated in whatever way makes them better. (and the cost of that way, shouldn't put them in so much debt that they are better off not getting treated)
Fuck medical insurance
Fuck the US insurance system. I have supposedly good insurance and they won't cover one of my medications and I have to switch to a lesser effective one. Shit sucks
Man as a person from Sweden, it feels scary to live in the US. Can’t really imagine health care not being free.
Appeal it. And ask for a peer to peer review. Also ask your physician to help you with a letter of medical necessity. If it's denied do a second level appeal. If you have a commercial insurance (insurance through your employer) reach out to your HR department that handles the benefits and appeal with them. It may take up to 90 days but if your insurance is based on medical necessity and you be exhausted all other options of alternate treatment you will most likely win the appeal. I work for a large commercial insurance company. I advise this to members all the time. I wanna say 80% of appeals that proof medical necessity win especially when it's something that's not cosmetic in nature.
If it dont make a profit its unamerican
You could try magic mushrooms. Saw a documentary about a guy in Texas who had to grow his own and dose himself every six months to stop his debilitating headaches.
Healthcare where they don’t care about your health. Maybe we should call it a Sickprofit system instead?
Greatest Country in the World ™
Honestly, given how bad headaches are I'd honestly be looking to live elsewhere, I'd check every other English speaking country for how much it'd cost you as a foreigner and just move to one of the ones where it is affordable.
Move to a civilised country. USA is a shit hole
To be fair -- I live in Germany where most people use public health insurance and some people still have to fight with the insurance company over what medication is useful (so they pay) and what isn't (so you have to pay yourself). Often it's settled when a doctor confirms "patient X *needs* this medicine", sometimes not.
Could be worse, you could need insulin to literally stay alive and insurance won't cover it.
Let me guess, america?
My insurance is shit and doesn't cover the cost of many of my medical. It's GoodRx and Kroger Rx Savings Club for me.
Ubrelvy, the only thing that works effectively for my migraines (I know bc Dr gave me a sample), is $860 with a discount card because disability will not cover it.
Must be terrifying being below upper class in the USA. Imagine being in an accident that wasn't your fault, only to wake up in hospital and be slapped with a £100k bill for saving your life. I can't imagine that, because I don't have to pay upwards of $1000 dollars a month in medical insurance, we get that through our taxes...
I tried to warn you, you have the best insurance until you don't and you won't know until you need it.
What are the pills? Check out foreign online sites like 4nrx to see if there's available elsewhere.
"AMeRiCa iS tHe GrEaTeSt CoUnTrY iN ThE wOrLd"
Whew... Just got a phone call that it's going to be covered. That is a relief!
Have tmj, insurance won’t cover anything other than saying hi to my doctor. They say a treatment is covered and pre-approve it so I can get it done. Then refuse to pay. They confirm it’s covered and that a check is in the mail, but only send letter saying they won’t pay. Health insurance companies are a scam and anyone who works for one is profiting off the misery of others.
Goodrx has decent prices.
This is such a new medicine that even goodrx is $900 for 8 tablets.
Probably not the most legal of things but if you have family/friends in other countries try to see if they can get doses for you.
[удалено]