Need UC/Crohns Prescriptions? Don't ever get Healthfirst Insurance.

I can't find my old thread where I was complaining about finding out the cost of a prescription drug before enrolling in a healthcare plan. Well, low and behold, here I am enrolled, dramatic as can be, and about to run out of my medications.

I'm off the wonderful ride that is medicaid since changing jobs, and now under NYC's healthfirst Bronze plan. $120+/mo, $4000/deductible, covers nothing, welcomes disease to flourish...

Before enrolling, I contacted their pharmacy, my doctor, my CVS pharmacy, examined the drug formulary, anything I could to understand what my cost of Asacol HD or Rowasa might be. Nothing, no one could tell me. Couldn't even access a 'dummy member ID #' to estimate costs. I knew I would have to do a prior-authorization for these medications just like I did while on Medicaid.

Prior-auth and appeal have both been denied by Healthfirst, simply said my plan does not cover them. Now we're submitting a verbal appeal where I let them know I've tried many medications without fair results, caused side effects, and require the medications I'm asking. The formulary does not list any crohns/colitis medications.

I spent 45 mins on the phone with Healthfirst trying to present my case, as my doc recommended.

It's unconscionable that this company would deny my doctor's written request for coverage of these medications, and further suggest I consider 'other options'. This isn't a god darn diet, this is a patient's health. I'm irate over this, and the fact that if this next appeal is denied, I have to submit another to the state of New York, possibly wait 90 days and pay a $25 fee to do so. Unbelievable.

Anyone encountering similar issues? I can't catch a break. I'm in the beginning stages of my career -- one of those people admittedly who works 2 jobs day and night to barely provide, has student loans lined up along with this healthcare mess which is now threatening my ability to thrive. How I was making a similar amount per year and had access to medicaid, while now making just a bit more and have no access to what I need, is absurd.

Post Edited (stereofidelic89) : 6/27/2017 12:59:54 PM (GMT-6)

That's awful stereofidelic89. They've got to cover something for IBD. Below is a new thing from the resources secton that I wrote, mentions all of the available 5ASA/Mesalamine names and dosages which would be helpful in talking with your insurance, pharmacist, and doctor to see what is covered and at what cost.

Policies are getting crazy restrictive, mine makes me pay a percentage of the retail-cost of the medication, and if the medication is non-formulary and brand-named, they make me pay 40% of the list price (wonderful when it's a 30-day supply of Delzicol that costs $1,200), or a $480.00 copay each month... insanity.

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One of the biggest headaches when switching health insurance policies is you might have to change medications. Here's a basic survival guide to help you through it.

1.) Ask which UC medications are on the insurance's formulary (preferred) list and which are on their non-formulary (not preferred) list. For the lowest out-of-pocket cost, choose from the formulary list.

2.) Generics are the most cost effective. Brandnames are more expensive.

3.) Use the health insurance's price estimator tool (online insurance website, or call insurance, or ask a pharmacy) to learn what your copay will be. You will need to know which medications are applicable. The most common UC meds used are the anti-inflammatory, mesalamine-based medications that should be available in their price estimator:

• Apriso is brandnamed, comes in 375mg pills, a typical dose is 1,500 mgs or 4 pills daily. A copay assistance card is available from the manufacturer.
  
• Balsalazide Disodium is generic of Colazal, comes in 750mg pills, a typical dose is 6,750mgs or 9 pills daily.
  
• Colazal is brandnamed, comes in 750mg pills, a typical dose is 6,750mgs or 9 pills daily.
  
• Delzicol is brandnamed, comes in 400mg pills, a typical dose is 4,800 mgs or 12 pills daily. A copay assistance card is available from the manufacturer.
  
• Lialda/Mezavant is brandnamed, comes in 1,200mg pills, a typical dose is 4,800 mgs or 4 pills daily. A copay assistance card is available from the manufacturer.
  
• Mesalamine DR is generic, comes in 800mg pills, a typical dose is 4,800mgs or 8 pills daily.
  
• Pentasa is brandnamed, comes in 500mg pills, a typical dose is 4,000 mgs or 8 pills daily. A copay assistance card is available from the manufacturer.
  
• Sulfasalazine is a generic,comes in 500mg pills, a typical dose is 4,000mgs or 8 pills daily.
  

4.) Once you've found a cost effective medication, call your gasteroenteroligist for a new prescription.

5.) Mail order prescriptions may have lower copays when you get a 90 day supply, instead of a 30 day supply. Check with your health insurance and ask about mail order options.

The formulary on their webpage lists the folowing IBD drugs::

INFLAMMATORY BOWEL DISEASE

APRISO CAP 0.375GM tier 2
balsalazide disodium cap 750 mg tier 1
budesonide delayed release particles cap 3mg tier 1
CANASA SUP 1000MG tier 2
colocort ene 100mg tier 1
DIPENTUM CAP 250MG tier 3
mesalamine enema 4 gm tier 1
mesalamine rectal enema 4 gm & cleanser
wipe kit tier 1
sulfasalazine tab 500 mg tier 1
sulfasalazine tab delayed release 500 mg tier 1


assets.healthfirst.org/api/pdf?id=pdf_168e26de60&key=581b79b625f366a9947d96f98b0960fe00d3e667&_ga=2.177132770.631075117.1498670251-654589821.1498670251


I think Aspiro or Dipentum would be the most mainstream choices.

Post Edited (DBwithUC) : 6/28/2017 11:45:47 AM (GMT-6)

It is unsettling. It is also our "system". Formularies are a cost management tool, and as long as for-profit companies are part of the system, cost-management is a valid thing to do.

I think even under single-payer, there might be preferred formularies, and appeals needed to go off. I think a fairer system would be that the co-insurance for off-formulary could never be 100%. Even if it was 60%, you would have the option of choosing off-formulary and still get almost half paid for.

Ultimately we need to bring down these prices to levels seen in other countries so that people can afford them even without insurance.

If you get a chance to change plans next year, I think a better one for you would be one where off-formulary was a high co-insurance - but not 100%. The higher premium should be offset by drug cost savings.

good luck

Why should you have to change your meds? Because you chose a health plan that doesn't cover the ones you want to use. Looks like they publish their formulary for all to see. Your drugs weren't on that list.

Does it stink that they can limit your choices? Absolutely. It is a system that you can work around? Absolutely. Next open enrollment find a plan with a better formulary more to your liking.

When I got my diagnosis the first thing I did was started researching my options with my formulary so I could have some good conversations with my doc. My next step is a biologic, not one he would normally prescribe, but its on my formulary and by knowing that up front, I save myself time, money, and suffering by being able to start treatment more quickly.

Its not the best system, but its what we have. Learn to use it to your advantage rather than fighting it.

Gee, I wonder why private insurance is so expensive given their shoddy coverage:

UnitedHealth Group, latest disclosure on CEO compensation: $17.6 million; pay of next four highest paid employees combined: $37.6 million. 
 
Humana, latest disclosure on CEO compensation: $19.7 million; next four highest paid employees: $20.0 million. 
 
Secretary of HHS (who would be in charge in government sponsored single-payer health insurance): about $250,000, give or take.