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Insurance Co. says "We'll Save Your Life -But Don't Enjoy It"

WHW's picture
WHW
Posts: 189
Joined: Jul 2009

Let me see if I have this right.

My health insurance company has "Centers of Excellence" for just about all of life's large medical issues. Places they prefer you go to, to be treated. My surgeon and his facility fit into that category. The premise is that my Dr. is at the top of his game, is a vanguard on developing improved treatment and does so many of the procedures that the Insurance Co. feels after surgery complications will be minimal and less costly. Now this makes sense.

My Dr. obviously knows what he is doing. I left with a "Penile Rehab Plan", prescriptions for various drugs and a script for a medical grade VED, all of which are a part of the plan.

Okay, ready for it. The insurance company will gladly assist me in saving my life, but they don't want it to have any quality.

I called my pharmacy about filling the script for the Cialis. It is for 5mg tabs, to be taken once a day for 30 days and it has 12 months of refills. They told me my co-pay would be $60. Okay I can live with that. However, the insurance company will only allow for FIVE (5) pills per 30 day period. BTW it is the same for the script that I have for the Viagra 100mg pills.

I called the insurance company to discuss this. It would seem that these drugs are considered "Tier 3" drugs. Beating around the bush the representative so much as said that these drugs are considered "RECREATIONAL PHARMACEUTICALS". And don't even get me started about how the young lady laughed in my ear when I told her what a VED was.

My doctors office, as a part of the package, has also given me a letter in which they detail the plan and in bold-underlined text they use the words "medically necessary". They said that they have found it to be successful with a lot of the insurance companies if I have to go through the appeals process to get the prescription approved.

WHY THE HELL SHOULD WE HAVE TO GO THROUGH THIS?

I know that this is probably common knowledge to most of you. It wasn't to me. And I doubt if it will be to those that find us as they look for answers. It explains why there are so many posts asking about on-line drug companies and "alldaychemist".

My insurance company will pay for the shrink if I am depressed, physical therapy so I can get back on the ball field and well, you get the picture. But not to give me back the basic of man's instincts - to enjoy a good "woody". DUHH!!!

I was discussing this with my sister, who has had her own share of health and insurance issues. She relayed a story to me about a friend of hers that has been dealing with breast cancer. The friend had to have a mastectomy. When she was recovered from the surgery, the insurance company paid for the mental therapy for the depression and then paid for the reconstruction surgery, to the point where "she was at before the surgery".

That's all I am asking for. Hell I don't even need the mental work, YET!.

I plan to "Not Go Quietly Into The Night" on this one. I will attack this one on Monday. And BTW I have the young lady's name that laughed at my issues and will be talking to a supervisor about extreme sensitivity training.

So how many of you guys have run into this same scenario? Have you been successful in dealing with it? And if so, what hoops did you have to go through? And lastly, has anyone heard of this being addressed on a national level by some of the larger PCa organizations. Seems to me that this should be slid in somewhere with healthcare reform.

Looking for input on this one guys.

Thanks,
Sonny

NM
Posts: 214
Joined: Jul 2009

My insurance company (blue cross 0f ne pa.) You want em you buy em.. 106.00 for 6 100 mg. viagara.....Nice eh...Nick

WHW's picture
WHW
Posts: 189
Joined: Jul 2009

Oh yeah, and here is some additional info:

My pharmacy using my insurance $60.00 for 5 pills = $12.00 per pill (generic pill)

My pharmacy using NO insurance $143.00 for 30 pills =$4.76 per pill (same generic pill)

Walgreens using no insurance $120.85 for 30 pills = $4.02 per pill (yep, same generic pill)

And of course there are a gazillion online companies that offer the drug for $1 to whatever per pill. Obviously all of these prices are for generic pills (I'm guessing here), but it would seem that most of these are out of the country and country of manufacture is hard to discern.

Okay, it would appear that splitting the pills would be doable. My doc gave me a script for Viagra 100mg pills. If I split the 5 pills (# allowed by insurance co) into 4 this would give me 20, 25mg pills.

Has anyone had experience with 25mg viagra vs. 5mg cialis. I would have to alternate days of dosage using the 20 pills per month instead filling the cialis 5mg script.

Using 5mg everyday seems to make sense to get the blood flowing while I continue the rehab process. Will the 25mg viagra, I could take them 2 days then skip 1 and it would work out to the 20 per month, give me the same benefit?

Sonny

dopplerjockey's picture
dopplerjockey
Posts: 39
Joined: Jul 2009

Hey Sonny,
Oh, yeah, we have been down this same road. I posted on this discussion board not long ago about the entire unfairness of the charges that the drug companies exercise for their precious little pills. We have no drug coverage, thanks to Hewlett-Packard's retirement program that we are under. So... just last week, at Walmart, I paid $342 for 20 Cialis, 10 mg, ($17/pill) and I am supposed to take one each night, as part of my rehab program, as outlined by the urologist. Now, 20 pills won't even last me a month, but it was all that we could afford out of pocket.
And yes, when we talk about health care reform, this is the very thing that needs to be addressed. I don't begrudge a company making a "fair" profit, but charging me $462/month for 30 pills for ED meds is ridiculous. And you are correct, women with breast cancer can get so much better after cancer care, that we men do not receive. Definitely not a fair table to play these cards at.

I can't take Viagra, due to a previous episode of partial blindness while taking it, so can't answer you question there. I checked on alldaychemist, they can't ship to me Cialis unless I send them a letter verifying that the drug will not be consumed in the US. Guess I would have to travel to Mexico or Canada each evening before bedtime, take the damned overpriced pill, and then return to Clearwater, ID for sleep. Of course, this all stems from patent rights that the drug companies make sure that they get listed, and our US Congress backing them fully, as the drug companies keep shoveling dollars into the re-election campaigns of these crooks in Washington D.C.
So, we share your pain, and we agree, we all need to stand up and ***** like hell over this.
Good luck my friend.
Dallas

brookjax's picture
brookjax
Posts: 18
Joined: Apr 2009

I have been advised by docs that 10 mg. of Cialis is the regular dosage for this rehab treatment, with possibly a 20 mg. pill once per week. Or for Viagra, just cut it in half; the Cialis pills are made with a notch so that you can cut them in two easily. A 5 mg. pill may be too little.

I got Cialis initially at Walgreens with a Humana insurance, and ten pills were list priced at $115; $104 net cost/co-pay, so only a $11 insurance reduction. The insurance company told me that these pills are not on their drug list.

This does deserve a campaign in Washington. If those with every other illness can lobby for fair treatment, why can't we?

I have heard several people here use the Allchemist Cialis pills, so I think their letter requirement is just for their records and doesn't mean much. Everyone knows they sell these pills to Americans to use here. I got mine from a supposedly Canadian company, but I think the pills came from Asia from the strange return address. I haven't heard any complaints about generic pills, though. Has anyone?

My surgeon didn't seem to know squat about ED treatment by pills, and had to refer me to another doc for that when I insisted on trying them. My UR had samples of Viagra in his treatment rooms, so this isn't any secret. But I doubt they get enough samples to supply the normal needs of those needing them. I'm alternating between pills and Trimed, since I got a late start at this. I hope I'm not taking too much.

Speaking of the insurance rep, the doc's assistants don't seem to give much of a damn about us either. They kept telling me it might take 3-4 weeks for the Trimed to arrive; then someone overheard this and told me to expect a call within one business day after the prescription was to be faxed. Then the other assistants conveniently lost my prescription paper, and a week later I had to get the doc to write another prescription form for me. A week later I found that they had not faxed this one either, although they did locate it. I heard from the lab a day after it was faxed.

Ocean-View
Posts: 26
Joined: Jul 2009

See if your doctor can get you a 30 day supply of Cialis. They have a promotion going on that I think last until the end of the year. My doctor here in Orlando said he can give me the coupons for it.

Tom D Orlando

WHW's picture
WHW
Posts: 189
Joined: Jul 2009

I have an appointment with my local urologist in Winter Park tomorrow. I am going to bring him up to speed on my surgery and deliver a copy of the path report.

I will be sure to ask. I was going to ask about samples anyway.

I appreciate the input,

Sonny

lion1
Posts: 240
Joined: May 2007

I experienced the same thing. The system is all hosed up!!!! I tried to get my doctor to work this he tried--but had no luck.

Lion1

WHW's picture
WHW
Posts: 189
Joined: Jul 2009

So I went to my local uro today to let him know about the surgery and the path reports. I was discussing the Insurance companies and the meds stuff and he told me to wait a minute.

He left a came back with a bag. Gave me 56, 5mg Cialis pills and 6, 20mg Cialis pills.

Told me when I came back in a month for my PSA to remind him and he would give me some more.

Don't know, but I think he may be carrying a little guilt over being the one to diagnose me.LOL Whatever the guys sure is nice and it works for me.

Sonny

lion1
Posts: 240
Joined: May 2007

My Uro periodically give me samples, but since everyone is in the same both, they usually run out.

Lion1

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