LymeNet Flash: Anybody heard of this "Insurance only covers #20 pills at a time"?

This is topic Anybody heard of this "Insurance only covers #20 pills at a time"? in forum Medical Questions at LymeNet Flash.

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Posted by Dave6002 (Member # 9064) on :

When I picked up my Tindamax, I was told by the CVS pharmacist that the insurance(HMO) only covers #20 pills at a time. The prescription was 28 pills with 3 refills. So I had to pay $40 for 20 Tindamax pills.

[bonk]

Just feel so weird. [bonk]

Any idea?

Thanks.

Dave

Posted by hillaryb (Member # 10049) on :

Yes--many insurance plans limit the # of pills per month you can get.

With my insurance company, I can get more of the rx per month by having my doctor's office sumbit a form stating that I need more than the monthly alottment. If your doctor is an LLMD, his/her office should have lots of experience doing this.

Good luck!

Posted by Jill E. (Member # 9121) on :

Hey, 20 pills is more than my insurance usually covers at a time!

I could only get 10 Ketek pills at a time. Each 10 would cost me my co-pay and be considered a full prescription.

Basically, my insurance will only fill what the standard antibiotic dosage would be for that medication, say for a sinus infection. Like you, my prescriptions are usually written for 30, 60, 90 days or whatever, but the pharmacy never can get the insurance to pay for that.

I think it depends on the insurance coverage. A Lyme pal who lives in the same city as I do, and has the same insurance company as I do, gets her meds covered with no hassle (even including Bicillin which I have to pay out-of-pocket for).

The only difference is she has a group plan and mine is individual.

Jill

Jill

Posted by Dave6002 (Member # 9064) on :

Thanks Hillary and Jill for letting me know these weird things.

It seemed they changed abruptly. I have been with this company for awhile and got several prescriptions filled without any problem.

Just wondering if they have begun to use the new IDSA guideline to restrict medication.

Anyway, I may need to ask for the written policy.

Wish everybody the best.

Dave

Posted by Lymetoo (Member # 743) on :

That is so nuts that the insurance companies have so much control over our health care.

Posted by Lisianthus (Member # 6631) on :

Sometimes it depends on how the doctor writes the script. If he writes it that you take lets say... 4 a day, then sometimes they will cover for a whole months supply. But it depends on the insurance company.

Posted by trails (Member # 1620) on :

this is quite common with antibiotics precribed for long periods of time. particularly expensive ones. like tini and zithromax.
[Frown]

but you can get around it sometimes and with persistence.

call your LLMDs office and let them know. They need to call your script insurance and ask for a pre-auth to get you the meds AS THEY HAVE PRECRIBED THEM. Most LLMDs offices deal with this all the time, they should know what to do.

good LUCK!

Posted by bettyg (Member # 6147) on :

dave, you've gotten great advise above.

yes, i'd ask to read the INSURANCE POLICY about this and have them make a paper copy for you. [Big Grin]

Posted by mlkeen (Member # 1260) on :

My HMO makes changes on Jan 1 each year, so perhaps this why the sudden changes.

Generics seem to be no problem getting 90 pills per month after month for about $9.00, but Ambien is $40 for 14 pills with no refills.

Our HMO(Keystone) is actually running free generics for the first three months of this year to try to get folks to use generics.

Posted by BOEJR (Member # 1734) on :

Hi Dave,

This is the new norm for about two years now... Back in 2004 when I was on Zithromax they covered an entire month.

Suddenly, when I went for a refill I was told that the policy changed. I did also get a notice about a week later from BC & Bs saying they only covered 7 tabs a month!

That's not even a therapeutic dose!!! [bonk]

I think that we should form a new topic. One that lets us all know when a carrier changes his policy so we can imediately send letters/emails to the insurance commisioner or however is doing oversite and complain in group... Just a thought.

Julia

Posted by Lisianthus (Member # 6631) on :

I would take ANY prescription coverage at all at this point. We have been without prescriptions for the last 15 years. I usually get mine filled in Canada now. And still I spend about $150 a month just on Nystatin (the cheapest generic around too) [Eek!]

I am so glad that Walmart came out with their drug list for $4, and Doxy is on that list... [woohoo]

Meijer has their Amoxy completely Free! Too bad I am on Mino (which is not on the lists) [Frown]

Lisi

Posted by Geneal (Member # 10375) on :

Hi all. Just went to get my new prescription of flagyl filled today. I am to take one 250mg pill one time a week.

BC/BS only wanted to pay for four pills!!!! How lovely.

Walmart pharmacy said I can give you 30 days of generic flagyl for $4.00.

I took it. Hope it is as good as the name brand.

Geneal