My wife takes Apriso daily, which runs $130 for a 90 day supply.

She went for a refill today, and they quoted her $475 for 90 days.

In talking with the insurance company, they informed me that the price went up because in December they came out with a generic version.

Good news, right? We should get the generic and save some money. .

No. . . in having the pharmacy run the generic version through, we discovered the insurance company does not cover it.

So even though there is now a generic option, we are still forced to pay for the brand? And a price increase at that?

Makes zero sense. I'll be calling the insurance company back tomorrow to see if the Dr. can call and get an exception for them to cover the generic.

Is the generic on your pharmacies $4/$10 list? Places like Walmart, target, grocery stores, etc. all have their own version of generic drug lists which you can fill a 30-day supply for $4, or a 90-day supply for $10.

The added plus is you don't even need to have insurance coverage, and if you do, you don't need to run the RX through your medical plan.

Back to the insurance side of your post, it sounds like your carrier simply has not had the time/taken the time, to update their generic list. Hopefully your phone call will help spur the process.

quote:

Is the generic on your pharmacies $4/$10 list?

No, Walgreens quoted more than what it'd cost for the brand run through insurance. Perhaps I can see if Target or Walmart can do something.

Insurance companies are tricky. Sometimes there are multiple options for drugs, some name brand and other generic. The insurer will have some sort of special deal with one brand but not the others.

I take the very same maintenance medication where one of the name brands is less than the generic through insurance. My insurer prefers Lialda.

Generics for this are not new. They have been available for several years. I have taken Asacol, a generic, and now Lialda. Even though the medication is "the same", the generic worked the worst for me, and I have had the best luck with the Lialda.

I would call the doc who prescribed the drug and see what he thinks before switching. It is all about deals between drug companies and Pharmacy Benefit Managers. I would be willing to bet there is a lower cost alternative covered by your insurance.

quote:

Originally posted by ZSMICHAEL:
I would call the doc who prescribed the drug and see what he thinks before switching. It is all about deals between drug companies and Pharmacy Benefit Managers. I would be willing to bet there is a lower cost alternative covered by your insurance.

There may be, but as the previous poster said, people had different results on different meds. My wife has tried a few throughout the years.

It sucks that we have to contemplate switching, and being worse off health-wise, because of the insurance company.

quote:

There may be, but as the previous poster said, people had different results on different meds. My wife has tried a few throughout the years.

^^^
I agree. Call the doc first. Authorization which is generally noncompensable time for the doc may be required. His staff should know. In other words, documenting the drugs that have not worked in the past so that the drug that works can be approved.

I would persist. Please post back with your findings.

If the prescription wasn't written to allow generic substitution, a pharmacy has to give you the name brand. Doc can call it in for generic. If your insurance Rx plan has a website, see if you can get price quotes for name brand vs. generic.

The craziest thing I've seen is insurance requiring pre-authorization for a drug, and then being charged full retail price for generic, which was still very expensive. Zero discount from full retail (I have an HSA plan so I pay whatever the negotiated rate is for each drug). But if I used the GoodRx discount card - I could pay up to 90% less depending on the pharmacy. Only difference is anything bought on GoodRx doesn't to towards the insurance deductible.

You might try GoodRx and see what the pricing is - it's good to always check if it's lower than insurance.

quote:

I would persist. Please post back with your findings.

First of all, excellent customer service from the insurance company. It's Magellan RX. I got a supervisor on the phone quickly, who immediately understood the issue. He said he'd call the pharmacy to have them run the script in a way which honors the price that we were paying for brand. 10 mins later, he called back and said it's taken care of.

Meanwhile, my wife's doctor said it could be many months before the insurance company covers the generic version. It's simply too new at this time. She offered a 30 day supply 'sample' to my wife while we get this sorted out.

quote:

First of all, excellent customer service from the insurance company. It's Magellan RX. I got a supervisor on the phone quickly, who immediately understood the issue. He said he'd call the pharmacy to have them run the script in a way which honors the price that we were paying for brand. 10 mins later, he called back and said it's taken care of.

^^^^^^^^
Good to hear.

Good news about the supervisor at Magellan treating you right.

Back to the $4/$10 deal, the last time I checked Walgreens is one of the few that does not offer the program. You can check the websites of Target/Walmart/your local grocery/Sams/Costco as each retailers list of $4/$10 drugs can/will be different.

Another option is to contact the drugs manufacturer and see if the will offer the drug to you on a hardship type reduced rate basis. A bunch of companies do that and write it off.

quote:

Originally posted by dwright1951:
Another option is to contact the drugs manufacturer and see if the will offer the drug to you on a hardship type reduced rate basis. A bunch of companies do that and write it off.

I take a brand name blood pressure medicine. It started getting expensive even with insurance. There is supposed to be a generic alternative, but no one produces it yet.

My old lady went searching online and she found a discount card directly through the manufacturer. I was skeptical at first but when I tried it it worked. It plus my insurance brought the price down to as low as it's ever been.

Have to renew it after so many uses, but they are good about sending reminder texts.

quote:

Originally posted by dwright1951:
Another option is to contact the drugs manufacturer and see if the will offer the drug to you on a hardship type reduced rate basis. A bunch of companies do that and write it off.

Our daughter has an inhaler she uses that is the same $400 for a 90 day supply, we have an HSA so that's out of pocket for us, the Pharmacy at Costco researched and found a Manufacturing coupon that cuts it to $30.

Good luck sounds like they are working on it for your, my wife works in this area, drugs become available all the time and they are not on the approved list since the list was out first, carriers are having to add them, get them approved and into the system, as much as we'd like it's not a quick process due to the scale of the market.

I ran into this with Advair. Generic Wixella came out and was filled. Was not yet on insurance RX list. Cost more that Advair

Try Sam's especially if you are a SAM's Plus member ($100 per year vs $50 for the reg membership).

I have been pleasantly surprised how economical most drugs there are, even vs mail order in most cases.

Out of curiosity I went over to Magellan's prescription drug site to see how they ranked your wife's medications.

Apriso is their preferred brand name. They have no preferred generic, and all of the other options are non-formulary.

Seems odd.

Have your doctor lean on the insurance weasels. You should lean on them too. I’ve found the generic bring available before it hits the weasel system. It’s frustrating and time consuming but it works. My generic was out of stock for months at my plan covered pharmacy. It was in stock at the competing chain. Out of pocket for the generic wasn’t an option. List price for the name brand through the insurance company wasn’t an option. A few hours, mostly on hold, with the insurance weasels and they told me exactly what to tell my doctor to tell them so I could get the name brand for the correct covered cost until the generic came back on line. Good luck.

Is your insurance thru work?
If it’s not a government funded plan, Apriso has a copay card that pays $100 a month of your copay. It’s on the website.
Just about any name brand med has a copay card. Just can’t use it with govt funded programs.
I do this every day at the pharmacy for patients.

quote:

Originally posted by zipriderson:

quote:

Is the generic on your pharmacies $4/$10 list?

No, Walgreens quoted more than what it'd cost for the brand run through insurance. Perhaps I can see if Target or Walmart can do something.

It was interesting, I started using that GoodRX app, and it quotes the medicine at all the local pharmacies. Walgreens always ends up being the most expensive compared to Safeway, King Soopers, Walmart, and Costco. By a lot of $ in some cases.

I was really annoyed having used Walgreens for a long time, but now my insurance plan doesn't cover through them, only their mail order and then the grocery stores. Once I saw the price differences, I don't mind anymore.