I have new insurance as of Jan 1st and this insurance is doing the same thing as my last insurance.
NOT accepting my doc's script for diflucan---or fluconizol.
The reason has yet to come--they mailed a letter--wont tell me on the phone.
Anyone else have coverage problems with this drug?
I have had to pay $12 a pill before b/c express scripts wouldnt cover it either.
Any suggestions? Thanks yall Posted by timaca (Member # 6911) on :
HI ya Trails~
Make sure you get a copy of your policy (what is and what isn't covered) and a copy of the drug formulary.
The letter that they are sending will help you figure out why they won't cover it.
Then refer to your policy and the drug formulary and see if you can refute their reason for not covering it.
Usually you can.
They are counting on you not responding.
Hang in there.
Timaca ps..New Mexico was awesome...more later. Posted by cantgiveupyet (Member # 8165) on :
i only had the problem that they wouldnt fill it because my 30 day supply wasnt up yet from the prior script.
I wonder if it is the qty they are having a problem with.
what was the dosage and qty.
its odd that it wouldnt be covered esp the generic.
Posted by trails (Member # 1620) on :
Timaca I was so excited to see you! You are back so soon?? Cant wait for the details!
I cant believe they are denying the generic either. But my last company did too and I FOUGHT it like mad. But they said that Lyme and the other co's did not show a suppressed immune system......HA! We only WISH!
I couldnt get them to cover it at all.
If they deny based on your diagnosis how can you really appeal?
The people I would TALK to were like---uh, you are on all these ABX for HOW LONG>>??? And I said....yeah, you think about that and tell me I dont need an intifungal...when was the last time you took a round of abx without some monostat hon?
But I faxed and sent letters--NADA. They wouldnt budge.
I actually wrote a whole story about it....but it is 8 pages long.
Was wondering if anyone else is having problems getting this filled.
How else could my doc write the script---like if it was a GYN---maybe they would write it differently????
I was Rxed only 1 pill per WEEK....so not tons here people.
Posted by cantgiveupyet (Member # 8165) on :
wow trails thats just beyond odd. maybe your name is flagged in the system, thats the only thing i can think of.
how to the insurance companies find out you have Lyme....im just waiting for them to start with me.
I know gyn's usually rx 150mg one pill....but from the sounds of it they wont even give you one pill.
i hope you get to the bottom of all this.
Posted by trails (Member # 1620) on :
they know coz of the diagnosis codes.
I have gotten diflucan from my gyn before but only one at a time 3 refills.
Posted by bettyg (Member # 6147) on :
Someone posted about this before; I pay $9 pill billed to my insurance company; but I pay $30 max at tier limit.
Someone said to buy at COSTCO; bottle is $30 dollars for 30 days.
Trails, I think I read somewhere where you are 15 years old; could your age afect this.
Posted by Jillybean (Member # 8071) on :
I had this problem just yesterday. My LLMD said they probably wouldn't fill it, and they wouldn't.
They gave me 7 generic pills for $31.00
At least they're paying for my antibiotics.....
Jill
Posted by treepatrol (Member # 4117) on :
quote:Originally posted by trails: I have new insurance as of Jan 1st and this insurance is doing the same thing as my last insurance.
NOT accepting my doc's script for diflucan---or fluconizol.
The reason has yet to come--they mailed a letter--wont tell me on the phone.
Anyone else have coverage problems with this drug?
I have had to pay $12 a pill before b/c express scripts wouldnt cover it either.
Any suggestions? Thanks yall
The BCBSNM/HMONM Pharmacy Benefit provides coverage of most drugs for our members. Effective communication about specific drug limitations is important for consistent benefit administration and customer satisfaction. The following information includes the drug limitations, exclusions, and prior authorization criteria for most BCBSNM and HMONM pharmacy plans. I. Drug Limitations A1. BCBSNM/HMONM 3-Tier Prescription Drug Plans: 30-day supply or 120 units, whichever is less per copay at retail pharmacies; or 90-day supply or 360 units, whichever is less per two retail copays at mail-order. A2. 25/50 Percent Prescription Drug Plan: 30-day supply or up to 180 units, whichever is less per copay at retail pharmacies; or 90-day supply or up to 540 units, whichever is less per two retail copays at mail-order. B. Drug-specific quantity limits are identified on the Dispensing Limit (DL) list below. Requests for larger quantities are referred to the BCBSNM Health Services department for review. Legend F Tier 2 copay applies NF Tier 3 copay applies * Not available through mail-order
::::::::::::::::::: ::::::::::::::::::
Drug DL Notes Abilify 30/30 days NF Aldara 12 (1 box)/21 days for 16 weeks F* Ambien 30/30 days NF Amerge 1mg, 2.5mg 9/30 days NF Axert 6.25mg, 12.5mg 12/30 days NF Azement 6/30 NF Bextra 30/30 days NF Celebrex 60/30 days NF Cipro XR 500mg 3/30 days NF* Crestor 30/30 days F Diflucan 150mg 2/30 days F DHE-45 150mg 10/30 days NF Duragesic 10/30 days NF Emend 12/30 days NF* EMLA 30gm tube/60 days F Fragmin 30/90 days NF* Frova 18/30 days NF Imitrex Inj Kits 3/30 days NF Imitrex Inj Vials 6/30 days NF Imitrex Nasal 5mg 1 x 1 pack of 6/30 days NF
oh now that one truly made me LOL! I only wish I was 15. I am more than double, but still a baby to some here. Thanks for the laugh though! Wonder where you saw that...hope it isnt based on my actions or posts!
Tree--- How did you know about BCBS/NM? Are you looking in my window right now? Well if you are I wouldnt be there coz I moved to CA--and the current drug company that is refusing is CAREMARK. But it is actually PersCare that is refusing.
And last year it was not the HMO but the PPO and it is overseen by NMPSIA (self funded plan--nm public schools insurance auth)--I am still working very closely with them (NMPSIA) on an appeal that is worth almost $10,000!
If I follow your post then I see that: 1-it is not available thru mail order 2-it is a second tier drug --meaning you would be repsonsible for a higher co-pay 3-you can only get it 30 days a time...or is the 30 pills?
I am not a member of costo--but I hear great things about their pharmacy. Maybe I should reconsider? I got the pills also out of pocket for $12 last year, since they wouldnt cover them.
Maybe my doc should resubmit the script as a yeast infection diagnosis?
thanks sooo soooo much everyone, I think I am seeing a light here! You guys really are the best! You just keep thinking I am 15 and things are gonna be just fine between us! trails
Posted by trails (Member # 1620) on :
Update 3/29/06
My doc's office re-submitted the prescription with the diagnosis as yeast infection. I recieved 15 pills as my 90 day supply for the generic $10 co-pay. This is much less than the 90 pills first prescribed.
This was the best they could do. Better than nothing for sure!
It did end up being the diagnosis that held up the med before. They wouldnt relenquish any diflucan if there was not a diagnosis of yeast.
thought you should know, Trails
Posted by bettyg (Member # 6147) on :
Trails, thanks for the update!
Somewhere when I read about a 15 yr. old girl; lucky you ... more than double that! LOL. Glad I made you laugh at least.
I thought that was interesting also about Costco being $30/bottle for 1 month.
Glad you got a better deal, but wouldn't hurt to look into costco too if it's out of pocket. Take care Trails.
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