Non-formulary Drug - Update at the end

R

Ratatosk

Administrator
Staff member
Ran to the pharmacy over the noon hour and noticed that instead of being charged a $15 copay for a one month supply of actigall (urisidol), I was charged $80. DS has been on this med for 6 years and suddenly today it's become a non-formulary drug.

We pay 20% for meds plus $15 or $30 (for more than a 1 month supply). Once we meet our out of pocket max of $1000 for meds, we just have to pay the copays. So why suddenly has it changed. DS is too little to receive the capsules of actigal which ARE a formulary drug -- the suspension according to his insurance company is not. Each month the pharmacist opens up capsules and puts them in cherry sugar syrup base and each month I pay them $15. Ugh!

Adding to my frustrations, last month I got charged double copay for a months supply of tobi. Like everyone else he's on it every other month, but insurance has decided that because I fill it every two months, that it's a two month supply. Ugh!

Banging my head against the wall. Insurance said they'll 'check into it'. Sigh!
 
R

Ratatosk

Administrator
Staff member
Ran to the pharmacy over the noon hour and noticed that instead of being charged a $15 copay for a one month supply of actigall (urisidol), I was charged $80. DS has been on this med for 6 years and suddenly today it's become a non-formulary drug.

We pay 20% for meds plus $15 or $30 (for more than a 1 month supply). Once we meet our out of pocket max of $1000 for meds, we just have to pay the copays. So why suddenly has it changed. DS is too little to receive the capsules of actigal which ARE a formulary drug -- the suspension according to his insurance company is not. Each month the pharmacist opens up capsules and puts them in cherry sugar syrup base and each month I pay them $15. Ugh!

Adding to my frustrations, last month I got charged double copay for a months supply of tobi. Like everyone else he's on it every other month, but insurance has decided that because I fill it every two months, that it's a two month supply. Ugh!

Banging my head against the wall. Insurance said they'll 'check into it'. Sigh!
 
R

Ratatosk

Administrator
Staff member
Ran to the pharmacy over the noon hour and noticed that instead of being charged a $15 copay for a one month supply of actigall (urisidol), I was charged $80. DS has been on this med for 6 years and suddenly today it's become a non-formulary drug.

We pay 20% for meds plus $15 or $30 (for more than a 1 month supply). Once we meet our out of pocket max of $1000 for meds, we just have to pay the copays. So why suddenly has it changed. DS is too little to receive the capsules of actigal which ARE a formulary drug -- the suspension according to his insurance company is not. Each month the pharmacist opens up capsules and puts them in cherry sugar syrup base and each month I pay them $15. Ugh!

Adding to my frustrations, last month I got charged double copay for a months supply of tobi. Like everyone else he's on it every other month, but insurance has decided that because I fill it every two months, that it's a two month supply. Ugh!

Banging my head against the wall. Insurance said they'll 'check into it'. Sigh!
 
R

Ratatosk

Administrator
Staff member
Ran to the pharmacy over the noon hour and noticed that instead of being charged a $15 copay for a one month supply of actigall (urisidol), I was charged $80. DS has been on this med for 6 years and suddenly today it's become a non-formulary drug.

We pay 20% for meds plus $15 or $30 (for more than a 1 month supply). Once we meet our out of pocket max of $1000 for meds, we just have to pay the copays. So why suddenly has it changed. DS is too little to receive the capsules of actigal which ARE a formulary drug -- the suspension according to his insurance company is not. Each month the pharmacist opens up capsules and puts them in cherry sugar syrup base and each month I pay them $15. Ugh!

Adding to my frustrations, last month I got charged double copay for a months supply of tobi. Like everyone else he's on it every other month, but insurance has decided that because I fill it every two months, that it's a two month supply. Ugh!

Banging my head against the wall. Insurance said they'll 'check into it'. Sigh!
 
R

Ratatosk

Administrator
Staff member
Ran to the pharmacy over the noon hour and noticed that instead of being charged a $15 copay for a one month supply of actigall (urisidol), I was charged $80. DS has been on this med for 6 years and suddenly today it's become a non-formulary drug.
<br />
<br />We pay 20% for meds plus $15 or $30 (for more than a 1 month supply). Once we meet our out of pocket max of $1000 for meds, we just have to pay the copays. So why suddenly has it changed. DS is too little to receive the capsules of actigal which ARE a formulary drug -- the suspension according to his insurance company is not. Each month the pharmacist opens up capsules and puts them in cherry sugar syrup base and each month I pay them $15. Ugh!
<br />
<br />Adding to my frustrations, last month I got charged double copay for a months supply of tobi. Like everyone else he's on it every other month, but insurance has decided that because I fill it every two months, that it's a two month supply. Ugh!
<br />
<br />Banging my head against the wall. Insurance said they'll 'check into it'. Sigh!
 
T

TonyaH

Guest
Non-formulary Drug

The insurance battle is so frustrating! My husband's employer offers what would be considered a very good health/Rx plan for anyone without a serious medical condition. We started having problems with Andrew's meds falling off of their formulary list about 5 years ago, and then a year and a half ago all of our, what they are calling "specialty medications", are paid at 20% or a $250 copay, whichever comes first. So, every time I order TOBI and Pulmozyme it costs of $250 each. And..the "specialty" pharmacy does not allow 90 day scripts, so we have that bill every month.

I don't know what to tell you. I've called everyone I can think of...HR through employer, insurance company, Express Scripts pharmacy....It just is what it is. I'm sorry I have no advice for you, but wanted to let you know you are not alone!
Tonya
 
T

TonyaH

Guest
Non-formulary Drug

The insurance battle is so frustrating! My husband's employer offers what would be considered a very good health/Rx plan for anyone without a serious medical condition. We started having problems with Andrew's meds falling off of their formulary list about 5 years ago, and then a year and a half ago all of our, what they are calling "specialty medications", are paid at 20% or a $250 copay, whichever comes first. So, every time I order TOBI and Pulmozyme it costs of $250 each. And..the "specialty" pharmacy does not allow 90 day scripts, so we have that bill every month.

I don't know what to tell you. I've called everyone I can think of...HR through employer, insurance company, Express Scripts pharmacy....It just is what it is. I'm sorry I have no advice for you, but wanted to let you know you are not alone!
Tonya
 
T

TonyaH

Guest
Non-formulary Drug

The insurance battle is so frustrating! My husband's employer offers what would be considered a very good health/Rx plan for anyone without a serious medical condition. We started having problems with Andrew's meds falling off of their formulary list about 5 years ago, and then a year and a half ago all of our, what they are calling "specialty medications", are paid at 20% or a $250 copay, whichever comes first. So, every time I order TOBI and Pulmozyme it costs of $250 each. And..the "specialty" pharmacy does not allow 90 day scripts, so we have that bill every month.

I don't know what to tell you. I've called everyone I can think of...HR through employer, insurance company, Express Scripts pharmacy....It just is what it is. I'm sorry I have no advice for you, but wanted to let you know you are not alone!
Tonya
 
T

TonyaH

Guest
Non-formulary Drug

The insurance battle is so frustrating! My husband's employer offers what would be considered a very good health/Rx plan for anyone without a serious medical condition. We started having problems with Andrew's meds falling off of their formulary list about 5 years ago, and then a year and a half ago all of our, what they are calling "specialty medications", are paid at 20% or a $250 copay, whichever comes first. So, every time I order TOBI and Pulmozyme it costs of $250 each. And..the "specialty" pharmacy does not allow 90 day scripts, so we have that bill every month.

I don't know what to tell you. I've called everyone I can think of...HR through employer, insurance company, Express Scripts pharmacy....It just is what it is. I'm sorry I have no advice for you, but wanted to let you know you are not alone!
Tonya
 
T

TonyaH

Guest
Non-formulary Drug

The insurance battle is so frustrating! My husband's employer offers what would be considered a very good health/Rx plan for anyone without a serious medical condition. We started having problems with Andrew's meds falling off of their formulary list about 5 years ago, and then a year and a half ago all of our, what they are calling "specialty medications", are paid at 20% or a $250 copay, whichever comes first. So, every time I order TOBI and Pulmozyme it costs of $250 each. And..the "specialty" pharmacy does not allow 90 day scripts, so we have that bill every month.
<br />
<br />I don't know what to tell you. I've called everyone I can think of...HR through employer, insurance company, Express Scripts pharmacy....It just is what it is. I'm sorry I have no advice for you, but wanted to let you know you are not alone!
<br />Tonya
 
R

Ratatosk

Administrator
Staff member
Non-formulary Drug

Apparently Urisidiol capsules are covered but the name brand Actigall is non-formulary. Suspensions are not covered -- only capsules.

An insurance rep just called me back and said previously it was a system issue -- the way the pharmacy submitted it, was allowing nonformulary drugs to be covered. That I was lucky they don't go back and charge me $650 (last 10 months) for the error. Sigh!

Wonder how much DS has to grow before he can take the capsules.

Friend of mine went thru something similar recently with creon a couple months ago. I guess they changed the formula, she went to pick up her child's script and was told it was some ungodly amount $1500? Because it wasn't on the list. Think she had to borrow money from family just so her kid could eat. Just noticed on the insurance drug list that they JUST added it as a formulary drug in October.
 
R

Ratatosk

Administrator
Staff member
Non-formulary Drug

Apparently Urisidiol capsules are covered but the name brand Actigall is non-formulary. Suspensions are not covered -- only capsules.

An insurance rep just called me back and said previously it was a system issue -- the way the pharmacy submitted it, was allowing nonformulary drugs to be covered. That I was lucky they don't go back and charge me $650 (last 10 months) for the error. Sigh!

Wonder how much DS has to grow before he can take the capsules.

Friend of mine went thru something similar recently with creon a couple months ago. I guess they changed the formula, she went to pick up her child's script and was told it was some ungodly amount $1500? Because it wasn't on the list. Think she had to borrow money from family just so her kid could eat. Just noticed on the insurance drug list that they JUST added it as a formulary drug in October.
 
R

Ratatosk

Administrator
Staff member
Non-formulary Drug

Apparently Urisidiol capsules are covered but the name brand Actigall is non-formulary. Suspensions are not covered -- only capsules.

An insurance rep just called me back and said previously it was a system issue -- the way the pharmacy submitted it, was allowing nonformulary drugs to be covered. That I was lucky they don't go back and charge me $650 (last 10 months) for the error. Sigh!

Wonder how much DS has to grow before he can take the capsules.

Friend of mine went thru something similar recently with creon a couple months ago. I guess they changed the formula, she went to pick up her child's script and was told it was some ungodly amount $1500? Because it wasn't on the list. Think she had to borrow money from family just so her kid could eat. Just noticed on the insurance drug list that they JUST added it as a formulary drug in October.
 
R

Ratatosk

Administrator
Staff member
Non-formulary Drug

Apparently Urisidiol capsules are covered but the name brand Actigall is non-formulary. Suspensions are not covered -- only capsules.

An insurance rep just called me back and said previously it was a system issue -- the way the pharmacy submitted it, was allowing nonformulary drugs to be covered. That I was lucky they don't go back and charge me $650 (last 10 months) for the error. Sigh!

Wonder how much DS has to grow before he can take the capsules.

Friend of mine went thru something similar recently with creon a couple months ago. I guess they changed the formula, she went to pick up her child's script and was told it was some ungodly amount $1500? Because it wasn't on the list. Think she had to borrow money from family just so her kid could eat. Just noticed on the insurance drug list that they JUST added it as a formulary drug in October.
 
R

Ratatosk

Administrator
Staff member
Non-formulary Drug

Apparently Urisidiol capsules are covered but the name brand Actigall is non-formulary. Suspensions are not covered -- only capsules.
<br />
<br />An insurance rep just called me back and said previously it was a system issue -- the way the pharmacy submitted it, was allowing nonformulary drugs to be covered. That I was lucky they don't go back and charge me $650 (last 10 months) for the error. Sigh!
<br />
<br />Wonder how much DS has to grow before he can take the capsules.
<br />
<br />Friend of mine went thru something similar recently with creon a couple months ago. I guess they changed the formula, she went to pick up her child's script and was told it was some ungodly amount $1500? Because it wasn't on the list. Think she had to borrow money from family just so her kid could eat. Just noticed on the insurance drug list that they JUST added it as a formulary drug in October.
 
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