Insurance agreed to cover specialty medication not on formulary- if I pay $2606.07 per bottle.
Hey all. So long story short, all of the fun starts with me switching to Kaiser. I submitted a request for them to cover a specialty medication not on their formulary. This was a medication that my previous insurance covered (I used to only pay a $20 copay). My doctor signed off on it and confirmed that I have tried the other medication that’s on their formulary, which failed. After receiving confirmation from my doc, I received a letter that they would agree to cover the meds. What the letter neglected to mention is that they would only cover essentially a third of the retail price. Note, this medication is EXPENSIVE otc. If you look at it “discounted”, on goodrx it costs somewhere in the $7000-$6000 range per bottle. So technically they are covering a substantial amount. But still not enough for it to be affordable. $2606.07 is pretty much what I make in a month’s pay. All of that said, while I can technically live without these meds, my life is substantially more uncomfortable without them. Not being on them means constant discomfort which impacts my physical and mental health. So that said, I’d very much appreciate any comments from someone who has experience with Kaiser pharmacy. I’m not sure where else to turn.
submitted by /u/artdrudge
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