Co-Pay on Medicines

[stacey79]

I have a question for those of you with prescription insurance. My insurance works in a way that it has designated formulary and non-formulary drugs. If a drug is formulary, my co-pay is much less. If it is considered non-formulary, it is much higher. Elmiron, Ditropan XL and Levaquin are considered non-formulary by my insurnace. Both list their alternative prescriptions as Detrol. (I know that's a whole other issue on how Detrol can be seriously suggested as a substitute for Elmiron!)

What I have realized is that Elmiron, Ditropan XL and Levaquin are all produced by the same company. I was just wondering if anyone knows how the formulary and non-formulary thing works. I have asked my insurance company a couple of times but no one is really able to explain it at all. Do any of you take these medicines and have them considered formulary? I'm wondering if the formulary/non-formulary list is a government sort of thing or if it varies from one insurance company to the next.

Thanks so much!

[dyno]

I think if it were me I would try to fight the elmiron because there is no other drug substitute for that. Maybe your Dr. could help you with this. It is the only FDA approved oral medication for IC and it is not available in generic. I think when I was getting Elmiron, I had to quit due to side effects, I was getting a 90 day supply for $30.00. The cheapest was $15.00 for generic, and then formulary were the $30.00.

[stacey79]

Thanks for your advice. I have tried fighting the Elmiron, but with no luck. I tried talking with the HR person at my husband's work who deals with the insurance, but she wasn't able to help me. I didn't think about asking my doctor.

THe non-formulary meds used to be $30 for a month, but they raised to $50 in January. I can get a three month supply for $100 by ordering through the mail. That does help a bit. My husband's allergy medicine is the same way. I don't think it would seem like so much if we didn't have so many that way, plus a few others that are $20 a month.

[windwalker]

I can only suggest talk to your doc about the Elmiron, there is no substitute, there may be a form he can fill out or something.

[Portia17]

There is no replacement for elmiron as far as I know and mine is considered non-fomulatary so my copay is high being 40.00 a month.

I also have like 8 others but most of them are 10.00 and it does add all up but I figured it out without insurance with all these meds the regular prices would be about 1000.00 a month so I am happy for the co-pay

[purplekris]

I was not on isnurance for the first year of elmiron and it costs $150 to $175 monthly depending on the pharmacy. I went bakc onto my company insurance since with this "Condition" I cannot get individual isnurance. they dropped formulary and it costs $20 since there is no generic. good luck, start the 'spare change' jar to help oot.

[missychan]

My personal experience has been that the "formulary or non" varies with the insurance company. Nothing to do with state or federal regulations. I'm on two meds that are "non" formulary, and all my doc had to do was fill out an "over-ride" request for the insurance company.

We had to show that we had tried any and all "formulary" alternatives and that they hadn't worked. In the case of a drug that has NO alternative, it may be different, but I know that with a little extra leg work from my doc, I was able to get the meds at the formulary co-pay.

Also- my son was on "DDAVP" for almost two years, and it was definately non formulary. I was paying over $450 a month cash... I fought like only a mom can, and finally got the ins. co. to cover it... at NO co-pay. It took over 4 months, but it was worth the fight. They would cover it for one condition, but not for the reason he was using it. DUH!

Good luck, talk with your doc... they're the ones that have to start the ball rolling. It's a fight, but if you're willing to stick it out, it's worth a shot. And- don't take no for an answer... you can and should file an appeal any time you get a negative response.

I was told by someone who works for ***** Insurance that sometimes they deny it the first time, knowing that they'll cover it if an appeal comes in. They just want to see how serious you are about fighting for it.

Hope you get it worked out!

Missy

[Dixiefireball]

will your inc. pay for heparin installments? Yes i know it can be a big pain by having to go to the doctor or mixing them your self. but heparin is a stronger form of elimron.
just a thought to get something in you coating the bladder that your inc. will pay for.

[jaime15]

I know and understand fully. I once paid a 20.00 co-pay when I worked. Now that I'm a sahm hubby's insurance only covers a *percentage*.....I know, I know, I should be thankful that we have some form of insurance.....but I pay almost 70.00 a month now for my elmiron script. And I have four other meds to fill also.
I guess if it continues to go up, I'll give it up. I refuse to pay anymore for it. Although it has been a lifesaver for me.

Dixie has a good suggestion for you....have you thought about the instills? If I have to someday go that route I will. But I really hate any med that is a cath......ugggggghhhh

I hope you figure out the formulary thing with your uro. :grouphug:

[redmowii]

I work in the medical field and am in charge of what we call PAP. Otherwise known as patient assistance programs. There are a lot of ways to try to get cheaper medicines. Number one, talk to your doctor, they understand perscriptions costing a lot and will try to help you.
If you don't have insurance, or have limited insurance another way you can try to get help is from the drug company's themselves. Many company's have patient assistance programs, and I find the best way to find which company's have which programs is a web site. http://needymeds.com/
I usually try to get patients help from there. If you can't find the medicine that costs a lot of money you can always try limiting the amount of money you pay for all the other medicines you are on. If one particular med doesn't have a genaric but other meds you have dose. Changing over might help a lot. I hope it all goes well for you.

[stacey79]

Thank you all for your wonderful suggestions. I guess I just assumed that there was nothing I could even try doing. I am very thankful to even have insurance. I can't imagine how difficult it would be without any insurance and, for the most part, ours is decent. The prescription coverage changing recently just stunk.

Part of what I'm wondering is if insurance companies don't partner with drug companies. For example, Detrol is approved, but Ditropan isn't. Ditropan, Elmiron and Leviqun are all Ortho McNeil drugs, but Detrol is Pfizer. Sort of makes me wonder. My mom recently got a prescription for Leviquin and only paid $6 with her insurance. I pay $50. So that got me to thinking about it.

I will talk to my doctor though. I will also check on the instills. I'm not fond of doing them, but if they would help and be cheaper, then that's not so bad.

I appreciate all your suggestions! :) (Man, I love the helpfulness on these boards!) :grouphug:

[MakinIT]

I think the formulary thing does depend on the insurance plan...My plan charges 10 for generic, 20 for name brand, and patient pays all cost if not on plan. (even though it says "Prior authorization" on many drugs, they NEVER authorize the drugs) I had a very good pain med that worked better than MS contin and they wouldn't authorize it. Well Butrin works well for me, but they will not give me a once a day pill although I struggle over and over with some aspects of the two times a day...(one is bizarre dreams, 2 sometimes insomnia, 3 sometimes wierd stuff during the day, all attributed to 2 times a day drug..)

yeah...other stuff...I get a surprise in the mail for a bill Iwasn't expecting, like they consider my instills (that take 5 mins) a "surgical procedure" so I wind up paying like 30 bucks each time + my doc copay. i know I can't complain b/c some folks have no insurance...it's just that my insurance coverage keeps sliding down every year, while my premiums go up.

T

[emilyrose197377]

I am having the same problem with my elmiron my hmo does not want to cover it even with a medical necessity letter. Good luck to you.

Take Care
KIM

[MakinIT]

There has to be something you can do, if that is what you want to take...I wonder if you contact the makers of Elmiron? see what they can do? I don't know if one little person is worth their time, they are such into profit making but if they can somehow convince your insurance company that that med is specifically for IC....of course, I'm prob naive...It is just so damn maddening. Those detrol drugs make it worse!!! I know, My first uro kind of used it as a preliminary non scientific test on me. If it didn't help or made it worse he figured it was likely IC (he told me this later) I cramped like hell on it.

I'm sorry for you, I feel terrible. In the meantime, are there some other meds or other treatments they will approve,,,(I was having a monthly marcaine, kenalog, and heparin treatment...kinda hellped but not for me to go through the time to do it.)

T

[stacey79]

THanks all for your input. I will check with my uro and see what he says. Basically I was just wondering how insurance determines what they will agree to pay the most for and it sounds like it's different for everyone. I have a feeling that drug companies sort of woo them and make deals on with them so the insurance will use their drugs. It seems very unfair. But, the whole health system is pretty much built around the rules of insurance. It is a pain, but I am glad I at least have insurance. I truly don't know what I'd do otherwise.

[mallenajolie]

I was wondering if anyone tried this. My insurance will only cover two packages a year! My uro wrote a letter, but it didn't seem to matter. He is one of the uros mentioned on this site. He tells me I am the only one he knows who it works for. Just suffer I guess without them. They would rather me take oxycontin I guess.

[MakinIT]

OMG you only get two packages for TENS electrodes? I assume you are referring to the little pads? Geez...when I was using TENS I got Pads when ever I wanted them. Now I use the RS sequential stimulator which is SOOO much better. A huge pain to put on but works so much better and they automatically send you new supplies each month.
How does your insurance company expect you to make electrical pads last 6 months...? can you afford to buy a set in between each set that is paid for?

Take care.

[songbird7]

I unexpectedly got asthma, hopefully from allergies so it won't be all year around and all of a sudden my co pays went through the roof. I had "walking pneumonia" and needed brand name to knock it out and brand name of other asthma med. This on top of the anti anxiety and anti depressants. This put me short last month and I am touching my small savings to get by. I've lived with my partner for decades and people put the two household incomes together so I don't qualify as far as I know for low cost meds. It's been really hard lately. I'd appreciate some prayers:)
hugs,

[stacey79]

I'm sorry that you are having such a rough time. It's hard enough when you aren't feeling well, but to add in financial woes, it's even worse.

I will keep you in my prayers. Sending warm hugs your way! :grouphug: :grouphug:

[mallenajolie]

Yes, two packages a year. My uro's letter sounded like I had advanced IC which I don't and they still wouldn't approve it. Oh well. No, I can't afford extras. I only use it when I really need to. I rely heavily on meds.

[MakinIT]

Man...that is sooo lame...those pads get so icky after about 3-4 weeks, what's the point of it if you don't use it? I mean...If you use it regularly, you don't have to (theoretically) use so much medicne. I myself am highly annoyned and fighting the system, once again. The Sequential Stimulator that works so wonderfully for me was turned down by my insurance co. I am so ******. Anytime I find something slightly off the beaten path that doesn't fit into their neat little catagory...box..., they turn it down. So, instead of a very helpful tool that decreases my need for at least 5 of my 15 mgs of valium and has kept my need to increase my morphine dosage at bay, I have to give it back, and use the stupid meds. (I could buy it, For like 400 bucks!!)

You know, It would be cool if somehow we could organize something where people could send stuff they don't use anymore for IC (and is sanitary, non prescription) and is available for folks who are lo income. I'm talking books, pillows, travel Johns, Tens Pads or Units, Maybe get companies to donate like therapatches...that kinda stuff...(like, I have travel Johns all sealed, I can't use b/c I can't pee in them...there is just no way) Maybe folks could send stuff to someones address...lo income pts could see if we had any stuff, maybe they could just pay postage...then...off it goes, I dunno...what do you think dixie...?

Off subject...My mind does that...I just get so frustrated at how we get so "screwed"..A) the disease itself B) the pharmecuticals C) the medical industry.....

Tracey

[mallenajolie]

I think that is a great idea for non meds. You should email Jill. This disease has made me low income. I am so behind on bills due to paying for scripts. Luckily, I am not at doctor's anymore, I don't even ask my uro whats new, I have kind of given up, the meds work somewhat, and I don't want any invansive procedures.

[ICNDonna]

I've been shopping for a TENS unit --- one place I checked, they told me that the set of TENS pads is only about $10. Maybe I should check further. We're on our own for the purchase of the unit and the pads.

Donna

[mallenajolie]

that is a good price for the pads, the last package of four was about 30.00 but this was at a hospital ran home medical supply. my insurance picked the cost of two packages a year. it was close to my uro and convenient. where did you see them for 10.00 after my second package I will be scrambling. I see them on the internet, but am a little hesitant.

[ICNDonna]

If I'm hesitant about a company on the internet, I email them first to ask where they are located so I can check at switchboard.com to see if they are a valid business.

I checked at a local medical supply place for the pads.

Donna

[MakinIT]

MellanJolie:Thanks for the support...it was just a "ding"....hey, what can we do with extra supplies...I think I'll talk to Dixie on the Lo income thread, as that is what she does....She can forward the idea to Jill if she thinks its a good idea...Maybe between Dixie and I we can figure something out.

[mallenajolie]

okay let me know I have lots of books on pain I would be willing to donate, thats about all I really have. i got them cheap off the internet so it wouldn't be any big deal.

[MakinIT]

yeah...Thanks..its still just a thought..I'm trying to get Dixie to reply and see what she thinks...I think our big issue would be postage...to get it to the "distribution center" and sent to those who need it. i don't know if we can get small cash donations and ask folks receiving the stuff to pay postage... we shall have to see...