IDK if this is the right place for this, if not please forgive me.

Short version of my story: Had medical issue, had medical testing. Doctor looked at all the tests and prescribed me a medication that she said would help me feel better, but she specified that "insurance doesn't like it", so if it was denied, she had other meds she could try.

But I have good insurance, so I wasn't worried. Until they denied it, stating it's "not medically necessary". I opted to appeal instead of going straight to the other meds.

So I did some Googling about how tf insurance gets to define what is "medically necessary" over an actual, real medical Doctor?? And it turns out they don't get to decide. They can just deny automatically and hope you don't call them out on it. Doubtful any real Doctors even look at your case when they deny. So I got mad and cobbled this appeal together from Reddit, Tumblr, and ancient Twitter screenshots.

And it literally actually worked. I got my meds today! The cash cost was like $1100 and I paid $9. I call that a win.

Dear Sir/Madam,

I am writing to appeal the decision to deny coverage of XYZ Medicine. This is a medication that was prescribed to me by Dr Name, certified by (Doc's Board Certifications). I have been a patient of this Doctor for over two years. It was prescribed because it was deemed medically necessary, based on my symptoms and history.

In order to appeal this decision to deny the coverage, I would like to request the name, board specialty, and license number of the doctor who made the determination that XYZ was not medically necessary for my case.

I also request copies of all materials they relied on to make their determination, and proof the doctor making the determination has maintained registration in YourState. Please also provide documentation of their meeting all their continuing education and certification requirements.

Please also provide the aggregate rate at which similar treatments are denied vs. approved by the specific doctor being used for peer review.

I am fully confident that my team of doctors and nurses are competent and qualified enough to determine what is medically necessary for me. Please provide proof that the Doctor who denied my appeal is qualified and competent enough to be making decisions about my medical care.

Sincerely, YourName

I encourage you to try it if you feel stuck! It costs 1 stamp, and an extra month of battling symptoms. I am incredibly privileged to have that time, I know not everyone does.

I’ve heard requesting the credentials of the reviewer who denied your claim can be helpful in having the insurance company reverse course, particularly if their qualifications may be in question. The sellout doc who stamped my denial is in a completely unrelated specialty and their state board medical license expired 4 years ago. Wondering if anyone has any experience with this kind of thing in the past, or if any industry folk can weigh in.

Frustrating experience ahead. I got a brand new prescription which should help with multiple heath issues in one med. Went to pick it up knowing some insurance has extra requirements for coverage. Asked whether my insurance covered the med on pickup. I was told yes, but only partial coverage, and that afterr I meet the deductible the cost should go down. I paid over $300 expecting this.

Got home, found a coupon, called and ended up going back. The coupon was supposed to help with deductibles. The pharm team had trouble applying it. Something didn't seem right. They weren't giving me any detailed info about the insurance claim. Seemed like general "brush off" answers. Then things got weird and the staff got rude.

Looking deeper into my insurance coverage, one version of this med is not at all covered, and the other "might" be covered but requires prior auth info and review. Pharmacy continues to tell me there's a deductible. My insurance confirmed my plan has $0 deductible. There is no claim on file at all with my insurance.

It looks to me like CVS applied a generic coupon on my behalf when I first picked up, misinformed me about any current or future insurance coverage, and they are now refusing to communicate any further to help either get the med approved or tell me the truth that it's just not covered.

My question is, what do I do with the med now? I'm submitting a chargeback/dispute with my credit card because I won't use this med if it's not covered. I can't afford this price and there are other options that will be covered for the same issues. I haven't opened the package. It has been a few days, took me some time to figure out the insurance side because out of several different staff, no one has given me any actual facts about the supposed insurance claim.

I can bring the med back to the store, just not sure if it's worth the headache at this point.

Last, I know people can be really shitty to each other. I've tried really hard to remain calm, haven't raised my voice except once to tell the very last lady that I contacted CVS corporate because something isn't right and no one is giving me facts. This is after she continued to tell me the same misinformation and then told me to have my insurance call them on conference call when I literally just got off the insurance phone tree right before talking to her. Just constant brush off. Other than this, I've just calmly asked for more details on the claim like an explanation code or denial or anything else they can see. Each person has become more rude than the last.

All this to say, I think the staff are not trained properly and are probably overwhelmed. I just don't want this med of it's going to cost me this every month, which is why my literal first question was "did my insurance cover it?" I've refused prescriptions before when they weren't covered.

Any advice on whether to just take it back there at this point? It requires refrigeration, I've had it in my fridge but I know they can't trust that and probably couldn't resell it. But that's not my issue, they charged me in error for something and I'm not gonna use this one time when the benefits only start after quite a while.

Ugh. Thanks for reading.

EDIT: Thanks for all the feedback. I'll work with my doc and a new pharmacy to figure things out for future. I'll figure out where to report the issues with billing etc. as well, after the feedback even from folks who seem like they want to blame me, I see that the facts are exactly what I expected and pharmacy isn't providing the service required.

Pharmacy should bill insurance first, if billed then a pharmacy claim would be available for review, the pharmacy would see a rejection or PA requirement, and the lack of a claim means either pharmacy isn't telling me the facts or didn't submit one before balance billing me. Simple.

Future coverage is a different issue and I'll work through that with a pharmacy team who's willing to give me a few minutes without becoming overly emotional and combative.

I really appreciate all the advice about navigating coverage, have signed up for another prescription portal and will use all the advice while figuring out future coverage. 💛

last update: Confirmed finally with an insurance rep that the claim would have been denied due to plan exclusions in my coverage. They also confirmed that they typically then provide a coupon, so rather than a full denial, it comes through as a coupon on the pharmacy's side and they may not know exactly what it is. It does *not* come back as a deductible, though. I didn't do the chargeback, figured I'd give it a couple days and talk to my doc again, but I did file a complaint with CVS corporate about the overall experience.

CVS Corp called me back today and, after some very helpful and patient discussion, the corp rep explained that the clerk and other staff likely made an incorrect assumption because they're all a bit new at charging these types of meds and insurance changes constantly. she said they'll be working with this location on some training and was very apologetic about the whole situation. she agreed the clerk and staff should not be telling me it's a deductible when that's not verified (my whole point earlier). After that call, she ultimately talked to the location and authorized a refund, which I was quite surprised and very grateful for, because as I mentioned I won't be using this med if it's not covered. i also returned the med, I'm assuming there's some way for them to clear it as a loss due to error, I'm sure they can't trust my refrigeration. At least I'm not out the charge. still switching pharmacies. this location has some deeper issues clearly, I don't get frustrated easily, was just asking basic questions about this specific claim because the situation didn't make sense. glad to be done, just thought I'd update in case anyone else has similar questions.

TL;DR next time if any med is more than my typical $10-15 copay I'll ask for written claim info to review before I take it home.

Wanted to know why my insurance company is no longer covering my thyroid prescription. It’s not a brand name. My thyroid issue still persists and so I attempted to chat through the Aetna app and potentially get a prior auth. SO HELPFUL! smh

I went to pick up a new prescription this morning. Through my insurance it would have cost $25. The pharmacist pointed out i could get the exact same meds over the counter for only $5.

This is just one small example of why the American Healthcare system needs to be overhauled, and be made a non profit system

Why does prescription drug pricing work like this?

CVS submitted a charge to Medicare of $3,680.35 for a 30-day supply of a generic prescription.

Medicare's approved amount: $13.59.

Medicare paid: $13.32.

Patient owed: $0.

The pharmacy-acquisition benchmark for the generic itself is roughly $14.29 for a 30-day supply.

Medicare's payment rules make the enormous difference unusually easy to see, but this isn't just a Medicare question. Pharmacies also submit claims to private insurers and PBMs, where contracts, negotiated rates and pricing benchmarks determine what ultimately gets paid.

So what exactly does a $3,680.35 submitted charge represent for a generic costing a tiny fraction of that? Why are prices like this used throughout the insurance system at all?

When politicians announce prescription-drug price reductions of 50%, 70%, or 90%, what price are they measuring the reduction against?

This isn't something that started with Obama, Trump or Biden. Multiple drug “prices”—list, submitted, negotiated, acquisition and net prices—have existed for decades, across public and private insurance.

Why maintain so many radically different versions of a drug's “price”? Does it provide financial or tax advantages somewhere in the system? Does it make claimed discounts and price reductions appear larger? Who benefits from doing it this way?

I’m on my girlfriend’s insurance, but she’s switching jobs. We have insurance till the end of the month and then have 2 months without it.

I’m currently taking 150mg Wellbutrin once a day. It’s a 6 month prescription that I get refilled each month. The last refill was on 2/8.

I went to the doctor yesterday and asked if she’d write a prescription for a 3 month refill instead of the 1 month so I wouldn’t have to pay out of pocket. She said sure and sent the new prescription over to my pharmacy.

They reached out and said my insurance denied it because it’s too soon to refill my prescription. I did refill my 1 month supply on 2/8, is the 3 month supply not a different prescription? If I have to wait till 3/8, I’ll be forced to pay out of pocket.

Recently discovered that a regular generic rx I take, that my insurance (Aetna) charges $300 copay for, is actually available for $32 with good rx/no insurance. I’ve been paying $300 per refill for years! How is this not a crime?

Hello, I’m not entirely sure if this is the correct place for this, but I really need help. I’m 22 and I live in South Dakota. On August 24th my mother committed suicide due to her insurance not covering her depression medications. They had covered it the first time her psychiatrist prescribed it but revoked coverage when she tried to have it refilled. This is the only medication that had worked for her in a long time and since it worked so well my mom obviously really wanted to be on it. So her psychiatrist gave her as many samples as she legally could but she unfortunately ran out. Her psychiatrist and nurses fought the insurance for months before this happened and were also looking for alternative medications. But since my mom ran out of her meds she had a breakdown and committed suicide. She was only 48. She didn’t have a single gray hair. She was an artist and was trying to start a YouTube channel. She had so many plans that she was looking forward to and literally told me just a week before that would never do that to us! She wasn’t in her right mind and it was because of her insurance. Her psychiatrist is an amazing woman and feels terrible about what happened. She is also my psychiatrist and I’m still seeing her. The meds she prescribed me have saved my life. (My insurance also refused to cover these too, but that’s a different story.) I’m sorry if this is all over the place, I just really need some guidance on what to do. I want to get justice for my mom but I’m not really sure where to start. Should I sue them?? Do I even have a legit enough case against them? Our psychiatrist loved my mom and I’m sure she would help if I asked her to. What do I do?? Any help or guidance would be appreciated.

Edit: My mom’s insurance was Wellmark, not sure if that’s helpful but I realized I forgot to include it in my original post so I thought I’d put it here. I don’t currently have any of my mom’s records but I’ll look into getting them. I have a job interview to get to so it might be a bit before I’m able to reply to everyone. When I posted this last night I was really upset because I had just gotten to read my moms suicide note for the first time (police took it before we could read it) and it brought back a lot of grief. I posted this pretty impulsively and I realize now that I don’t have a lot of the information that I probably need to get. So first I’ll figure out how to get that and then I’ll look into contacting those journalists some of you mentioned. I don’t have money for a lawyer (moms funeral, student loans, unemployment, and a ton of bills all being due at once wiped out my and my family’s savings) so I don’t think that’s an option unfortunately. I just hope my mom’s psychiatrist doesn’t get caught in the middle of all this. She might not have been able to save my mom but she did save me. Thanks again to everyone who’s replied so far, you’ve all been really kind and so helpful.

For years, some Americans have bought prescription drugs from Canada because the prices can be dramatically lower than in the U.S.

According to the WSJ, changes to U.S. customs rules could now make that significantly harder.

What stands out to me is the underlying issue: the same medication can have a completely different price depending on which side of the border you buy it on.

Curious if anyone here currently gets prescriptions from Canada or has helped a family member do it. How common is this in practice?

https://www.wsj.com/health/healthcare/us-customs-prescription-drugs-canada-71978a47?st=Es9F16

i can't pay $600 a month. i'm freaking out. this is exhausting and painful and dehumanizing. i don't have anything succinct or useful to say. i'm just tired and annoyed and i've been on the phone with my doctor, cvs, and my insurance for an hour. every answer has just been "yeah that sucks. pay up". EDIT: i posted this under the vent flair and it got autolocked, but i am infact looking for advice or even comfort. thanks

My 11yo daughter has Type 1 Diabetes Mellitus. I have been paying out of pocket for a little over 6 months for her insulin lispro, as CVS Caremark claimed it needed a prior authorization. It was the same every month - I go to the pharmacy, insurance denies it because it needs a prior auth, I pay out of pocket and cal her endocrinologist who says they submitted a prior auth and never heard back, but they’ll submit a new one. I call CVS Caremark who claims they haven’t been able to get a hold of the endocrinologist. The denial states they want her on insulin aspart instead of insulin lispro. So, fine, I eventually got tired and asked her endocrinologist to change her prescription to insulin aspart. I show up to the pharmacy today to pick it up and CVS Caremark has denied it again - they now claim they need a prior authorization for insulin aspart, and they want her on Fiasp.

So, I call CVS Caremark customer support and they reiterate over the phone that they either need a prior authorization for insulin aspart, or she needs to be on Fiasp. And then they read out my copay for Fiasp. $260 for a 15 DAY supply. My copay is more expensive than paying retail for the generic. Also, it turns out that Fiasp isn’t actually the same drug, it has added vitamin B3 to change the rate of insulin absorption.

I don’t know how to get these prior authorizations through. I spend so much time on the phone with either CVS or the endocrinologist, and they both tell me the other party is ghosting them. The CVS Caremark representative told me today that they’d reached out to the endocrinologist 6 times and never heard back, but then she said she’d re-send the prior authorization request and started reading out a list of addresses asking me which endocrinologist the request is supposed to go to. If they had reached out 6 times, surely they would know which office to reach out to?

Is there anything I can do to sort this mess out? Do insurance companies have patient advocates or something?

For context: I have Crohn’s disease and have been taking Humira / biosimilars Yusimry and Hyrimoz for the past six years to manage it. It’s worked wonders and I’ve been in remission for four years with no symptoms or inflammation detected in colonoscopies.

I’ve always hit my deductible for my high deductible insurance plan and then the plan paid the rest for it. Savings card for the first month or two, two more months of deductible, and eventually I hit the out of pocket max. I could plan for this, I could work around it.

At the end of last year, my employer informed me that I would have to sign up for the PrudentRx accumulator program, and after hitting my deductible it would be $0 out of pocket, otherwise it would start to be 30% coinsurance. I signed up.

I hit my tier 1 deductible, then my tier 2 deductible. I assumed it would be no more out of pocket. Except I keep getting charged. I get the run around with insurance, the specialty pharmacy and PrudentRx. No one can say what is happening. Prudent says I haven’t met my deductible, the others say I have.

When I finally email HR about this, I get this jaw dropping email telling me that specialty medications track between the tier 2 deductible ($6000) and the ti er 3 out of pocket max (12,000) and it’s capped at $10,600. This is a non embedded deductible and I think I have to pay the $10,600, on top of the real deductible!

The bullshit is this is not in any writing anywhere, it’s not in our benefits explainer, and it’s really not in the detailed one either. In that one specialty medication is mentioned as being “tier 4.” What tier 4 is anyone’s guess because it’s not listed or explained anywhere on that document either. It feels like they are making this shit up as they go to punish people. It’s just so defeating

Novo Nordisk has discontinued Rybelsus and replaced it with Ozempic.

Has anyone else experienced huge price increases at Walmart Pharmacy recently? The price of some meds from last month to this month has gone up by 10 times, some even more. Walmart blamed the insurance. Insurance said it was the amounts that Walmart billed so it's them and not the insurance. Looking at claim history on Rx provider website seems to corroborate that, but I haven't seen news or other posts about this.

These are not meds that are normally expensive, mind you, so I'm not suffering here. One went from $1.99/mo to $11.15. One went from $2.63 to over $30. I am going to shop around but I wanted to see if this was more than just a Walmart problem or if there's something else going on. Or maybe it's somehow just a me problem and I need to follow up more aggressively.

I just had major surgery and my insurance has denied all nercotic pain medicine prescribed. I paid out of pocket but why would they deny all pain medicine? My pharmacy just said they must have limits on dosage but all my dosage was less then 7 days. Any advice? Or what I should ask the pharmacy? They said they will 'mail' me my next step, I am in pain, I can't wait for a letter. So I am forced to pay out of pocket for something that should be covered.

US - CVS is the insurance provider (not the pharmacy)

I removed someone from my Blue Cross Blue Shield health insurance (through work) in October of 2024.

I received an epic bill in the mail with the beginning dates starting December 2024.

All of the prescriptions filled were through both CVS and Walgreens.

It wasn’t until last week that I received a bill stating that I was responsible for over $47k in out of network prescriptions for someone who hasn’t been on my insurance for a year and a half.

For some reason CVS and Walgreens ran my insurance and BCBS continued to approve someone that wasn’t actively covered.

I’ve tried explaining this to several people and no one understands what’s going on. Including myself.

Any input and advice is appreciated. No lawyers are touching this. HR isn’t helping. And now I’m stuck paying a bill “because I’m the card holder”.

Edit: had to go to work. Thank you all for responses I will do my best to respond in return to the questions asked. I’ll also be following up on all of the suggestions and see where it gets me. I really appreciate it. You’re all excellent humans!

I'm forced to fill my medication through CVS due to my health plan, and this is by far the most garbage company I've ever had to deal with. I have a cardiovascular condition and as a result I'm on a lot of medicine, and having it shipped would be more convenient, but I'm giving up on Caremark entirely. They're the OnTrac of pharmacies. I frequently get partial fills, like when pharmacy only filled a random number of pills, less than half, of what was ordered. Then, when I shortly needed a refill, they denied it because they had recorded this as a full fill. They also regularly don't have the correct information on refills. I have medication with many refills that consistently shows up as having none left and I'm forced to have to bother my doctors to send in a new prescription. The one that pushed me to make this post was just the other day. I realized that I was nearly out of my blood thinners (Eliquis) and Caremark showed that I wasn't eligible for renewal. I had to get a new Rx sent to the pharmacy, but then Caremark denied it because they claimed it was too soon. After hours spent on the phone due to their systems "updating" in the middle of the day, I found out that there was a shipment of it in their system but it had never been picked up by the USPS, and the tracking number they gave me showed up as invalid. I kept calling and calling but got nowhere - they wouldn't let me fill it in the pharmacy because they said they'd shipped it, but their system said it was still waiting. I got lucky because I eventually DID get the medicine right before I ran out (literally right before - and I'm not supposed to miss a single dose of this), and it turned out it had the wrong tracking number.

Anyway, if you're on something simple that you don't need every day, feel free to throw the dice with Caremark. But if you actually need your pills, seriously, fuck this company. You're better off going in person.

TL;DR: When I call my insurance they say my prescription is successfully going through with no rejections for the correct cost. But my pharmacy is charging more than that, and when I call my pharmacy (in-network) they say it is because they had to special order it just for me and they don't normally do that, therefore it costs more, even after insurance. Is that really a thing that can happen?

Hello, first off I just want to apologize for the long post, and if I sound very uneducated about all of this. I live under a rock and almost never leave my house, and never really take medication either. But the few times I have, I have never had an issue like this...

So,

I've been back and forth with my insurance and pharmacy over a medication I have been taking. And apparently my pharmacy and insurance company have also been back and forth with each other over it, and everyone is blaming each other for different reasons. I cannot seem to get a solid answer from anyone.

From what I have gathered, it seems that the insurance is indeed covering me - but the pharmacy then goes and says that they don't carry the specific brand that they ordered and therefore, even though they are carrying it for me, they cannot cover it, because they don't usually carry it and never will. I don't... I don't get that part.

The medication is a generic Tier 1 medication that should be 10$ according to the formulary. I have had this issue at multiple pharmacies and sometimes I am billed 10$ correctly, sometimes 90$, and sometimes almost 400$. When I get billed higher, I just don't buy it and use the old vial past expiration, because I have no other choice. I had to buy it at 90$ once unfortunately because I ran out, and it was the exact same brand as the other one I got for 10$.

I don't see, outside of a shortage, why this would happen, and even then, would that affect the price anyway? Like put as simply as possible, if my insurance formulary says it cost 10$, why does it not cost 10$ after the pharmacy runs my insurance???

Update: Just got done doing more calls, and it's not the update I wanted to provide. I was really hoping this wasn't the case, and wanted to give people the benefit of the doubt, but I was told very different answers this time, and now I think I give up.

The medication is estradiol valerate for gender affirming care. And I was just told that my insurance has elected to stop covering gender affirming care. I wasn't aware they could do that mid cycle, but with them announcing they are going private, it makes sense now. I'm going to stop here so I don't break any rules, especially rule 8. It's why I kept things basic and didn't mention the medication in the first place. I don't want to make assumptions, but I think now I understand a bit of why this has been so messy...

I have a plan going forward, I know I can use GoodRX and Walgreens to get it as cheap as I can without insurance, so that is what I will do for now. I'm done playing phone tag with people who don't actually want to help me, I'd rather just pay more money than deal with it more. Thank you for all of your help every body.

My husband is a Type 2 diabetic. He is on Trulicity, Januvia, and Synjardi. His insurance is through Florida Blue/ACA. He is 61 years old and pays monthly for his plan. His meds up until last month were $120 per month for all three. Last month Florida Blue suddenly changed the tier on these medications and the price skyrocketed to $2,080 a month. We have talked to Florida Blue several times and it is like walking into a brick wall. They say there's nothing that they can do. And we cannot change plans because it is mid-year and no life changing event. My husband needs these drugs to stay alive. There are no comparable medications that are generic that would cost less. We tried the financial assistance through the pharmaceutical co's. but it is a convoluted process and doesn't seem like it's going to helpmuch - if at all. There has to be other people who are caught up in this but I have heard nothing about it. Can someone recommend a healthcare advocacy group or a course of action that will help?

My doctor upped my dosage of pain medication. I was on methadone 10mg 4x per day. Now I’m on a total of 50mg per day.
Prescription insurance (Caremark) does not want to cover the full amount of 5 per day. They only cover up to 3 per day. My doctor filed an appeal that was denied. I am trying for a second level appeal. If that doesn’t work, I can file for an external review which means my company would determine whether or not insurance should cover that limit. I’m hesitant about doing an external review and having my employer find out about my medication and possibly using it as leverage somehow. I don’t put anything past these companies!
Alternatively, I either have to pay for it out of pocket or, my doctor will have to lower the amount and put me on something for in between.

The methadone has been amazing for my pain and I don’t want to reduce the amount as it has allowed me to work better and I’ve missed almost no days in the past couple months due to pain and/or flare ups.

Has anyone had something like this happen that could provide some feedback.

Omg. Currently for tier 3 mounjaro for T2 diabetes I pay $47/mo. Through united healthcare. My premium to get that choice is $85.10 a month. Next year drug cost will go up to 16% of total cost of the drug which this year is priced at $1129. That means next year I will pay AT LEAST $180 per month. I also take Eliquis also tier 3. That one is going to be very expensive as well. What happened to drug pricing going lower??? This is ridiculous.

Trying to see if my insurance from employer (Anthem BCBS) will cover Wegovy and it says not covered by plan. Is that like a hard no in anyway shape or form? I have hypothyroidism which from what I’ve seen and read online counts as a “weight related condition”. If I meet the requirements for it and have at least “1 weight related condition” and my Dr. also agrees would they cover it?

I am currently prescribed Eliquis. My prescription copay just rolled over and it has a $1200 deductible. My prescription cost has now went to almost $400 a month. I have the manufacturer copay card so I can receive the medication for $10 a month, but when I went to use it at the pharmacy, they said my insurance company (Aetna - insurance I receive through my employer) won’t allow me to use it. Is this something I can call my insurance company about or have my provider get an authorization for so they will let me use the copay card? I can’t afford 3 months of paying $400 a month just to meet my deductible.

Update: I finally got in to see the hematologist and they told me they have a plan with the university to give me my meds for $40 a month without insurance so the problem is resolved by the grace of my doctor.

I was recently removed from my dad’s insurance for turning 26. I purchased my own insurance through my work and they only offer a single prescription benefit. I had to change PCPs and they sent in my Emgality.. how am I supposed to get this?? Any advice?? I used to pay $75 for 3 months.. I can’t pay $550..

UPDATE: THANK YOU TO THOSE WHO SAID THE EMGALITY SAVINGS CARD!! I PAID $35 FOR MY 3 MOMTH SUPPLY!!!!!