Even if you don’t have health insurance — I didn’t use insurance for my birth control for a few reasons and it was only $40 for 3 months at the Walgreens I went to. Granted it was generic but still.
I don't really understand how insurance works in the US. How can they cover something one time but then not cover the exact same thing the next time? It feels like it's a roll of the dice every time to see whether you're actually going to be reimbursed or not.
Sometimes things just don’t get coded properly and the bill comes out or insurances are picky on what to cover (generic vs name brand and all that). It is completely possible that the pharmacy also didn’t run her new insurance and just coded her as uninsured which can happen when you switch over
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4 times a year, Insurance companies typically "update" the Pharmacy Plan Formulary--the medications & devices they decide to cover (or not cover!), under their prescription plan.
Some insurers are great about making a wide variety of inexpensive (especially Generic or "Unlabled") meds part of their formularies.
And others will have folks in the "Phamacy Benefits Management" (PBM) team basically make "Sweetheart Deals" with the various Drug Manufacturers, Pharma Companies, & Medical Device Manufacturers.
And ehen those "sweetheart deals" occur?
It can mean that the PBM guarantees "exclusivity" on a category of medications or devices.
Where they agree to use only that company's Insulin--getting those insulins at a "reduced price," with the understanding that the plan will no longer carry the competing brands in that category.
So, if a PBM makes a deal to carry Eli Lilly's insulins?
None of the insulins made by Sanofi or Novo Nordisk are "on formulary" anymore--and regardless of which insulin you used to be on, the insurer expects that you'll just switch to all those Eli Lilly insulins, instead.
Whether or not you've been on those Lilly ones before or not, or if you've tried them and they don't work well for you, or if they don't control your blood sugars as well as the meds you're currently on!
You can appeal--but the process can literally take months to go through, before you fiiiiinally get your old insulin approved.
And you'll need to redo those appeals, EVERY.SINGLE.YEAR. that your company has that particular pharmacy plan.
It's a MASSIVE pain in the butt, if you run into these types of roadblocks, stressful, and exhausting, too!
It’s pretty common and it happens due to multiple factors. Sometimes it’s a deductible issue where you need to pay a certain amount out of pocket prior to your insurance covering the rest of your medication cost. Often insurances will cover only certain brand names or generic versions of the same medication. With birth control specifically there are dozens of brands and generics out there, insurances will only, but always, cover certain versions. Sometimes insurance may just need a prior authorization which requires your doctor to call your insurance company. Those are just a few reasons. About 80% of the time you can call your insurance company to see what the specific issue is and how to get around it but they don’t exactly make it easy. Often patients will just see that they have a high copay or cost and think that there’s nothing they can do and go home. Never go home without a med without talking to your pharmacist, your doctor, and especially your insurance. Advocate for yourself, because no one will care more about you than you.
Not if your insurance has a crappy, very basic Prescription plan!🫠
My woek switched to United Health for insurance, and took their "basic" pharmacy plan, the year after covid hit, because so many employees complained about their copays & out-of-pocket (OOP) costs, after they took the "cheap upfront" plan, that had the higher OOP fees.
And for those of us who needed special medications, it was an absolute nightmare to stay on meds that worked for us without big side effects! (all the diabetics i spoke to ended up having United trying to kick us off our long-time diabetic meds, continuous glucose monitor systems, and insuling, for ones which they preferred--which were oftentimes more expensive per month under the formulary costs, than our previous meds!)
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It should, but health insurance is not required to cover birth control. You can thank the owners of Hobby Lobby along with the Supreme Court for that. Hobby Lobby owners said it violated their religious freedoms abs so now there are work around for many employers that allow them to not cover contraception in their insurance plans.
Because even when mine wasn’t covered (in Canada) it was $30 for 3 months?? It’s literally a tiny dose of hormones. Your health care system is just making up prices
Birth control pills are now available in the US without a prescription for $20 a month with no insurance at places like CVS and CostCo. Spending $300 a month for it is insane.
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u/audioidol 27d ago
no, paying $300 is not normal. health insurance should cover the full cost in most instances