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

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Posted 9/27/2009 12:52 PM (GMT 0)
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
Posted 9/27/2009 1:16 PM (GMT 0)
Yep, sorry to say, but that's the reality for probably 98 out of 100 of us here. Insurance companies won't pay, period. No amount of appeals, reasoning, etc. has been successful with the vast majority of them. It's an old-old story. I thought you were aware of the problem we have. ED drugs are considered recreational. If a com-pany will pay for them, it's usualy one a week, usually considered for sex, not for daily or 3x weekly therapedic. Now, almost all companies will pay for a VED. None I know of will pay for injection drugs either. That's why the large volume of traffic here concerning alldaychemists and such... I don't know if the same is true for Medicare/Medicaid, but do recall they were gonna give unemployed men free ED pills as part of the 'stimulus' package earlier. All we needed, depressed, out of work with time on their hands men with pills to pass the time... smhair Anyway, sorry- bad joke there... tongue
Posted 9/27/2009 1:27 PM (GMT 0)
Sonny,

God help you (and your wallet) if the Insurance does relinquish give you the thirty day supply -- that'll mean $60/5 pills = $300 co-pay a month! Ouch. (but maybe you can get 20 mg ones and get less pills -- usually the same co-pay per quantity of pills.

Ediit: I just realized that maybe they wouldn't charge a co-pay multiplied x 6 -- just some fixed amount. But you can never tell on that.

But yeah .. AllDayChemist is the less stressful way to go.
Posted 9/27/2009 1:46 PM (GMT 0)
Sonny,

What you describe is almost 100% of the case, a little surprised that caught you off guard. That's why there are so many posts about buying the drugs from outside the US. Is it unfair, absolutely. You may have to buy your drugs like many of the other men do here.
Sorry you had to find out after the fact.

PC is full of my unpleasant surprises.

David in SC
Posted 9/27/2009 1:48 PM (GMT 0)
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.

Here's another question; Can larger dose pills be split as we do with a lot of prescriptions?

Sonny
Posted 9/27/2009 1:51 PM (GMT 0)

Hey Sonny, glad to hear you're doing well.

As you've seen in the reply from James C., almost all of us have experienced insurance barriers post-treatment. It it fair? No. A couple of years ago I decided to have a cardio scan (CAT scan) done of my heart and 4 arteries to assess the need for statin medication, as my cholesterol has been high for years despite exersize, diet, etc.--I would pass the "gold standard" stress test they'd pay for with flying colors but could still be occluded, be at risk for a heart attack, and need medication. I underwent the test at my own expense ($850) and passed with a zero score in all 4 arteries (no plaque build-up) and then made a reasoned argument to the insurance company that the 850 would pale in copmparison to the expense of paying for statin medication for the rest of my life. Flat denial!.........so by all means, fight the good fight with the insurers, but the most important battle is the immediate one on your hands. So, do the alldaychemist routine, which is relatively cheap and works just fine. We can all hope that healthcare reform may address this issue in the future, but for now we have to take matters into our own hands.

When you embark on your road trip, and make the east coast swing, be sure to look me up here in the First State!

                             Arnie in DE

Posted 9/27/2009 1:57 PM (GMT 0)
Splitting the pills is fine. Before I had PC and the surgery, I was using Cialis and Viagra with the max sized pills. Then I would split each pill and got twice the usage. My doctor actually recommended it and had no problem with writing the script for the max dose. Your co-payment would be the same.
Posted 9/27/2009 2:27 PM (GMT 0)
Okay, it would appear that splitting the pills would be doable. My doc gave me a script for Viagra 100mg pills. If 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
Posted 9/27/2009 7:04 PM (GMT 0)
The remaining pills are going to be very small but since you just had surgery it's probably ok. I never split the 100 mg Viagra that much, just into two pills but this was before my cancer. The 100 mg Viagra dose would make me hard for a long time so after one experience, I never did it again.

Did you have your "nerves spared" on either side? I discovered after surgery that neither Viagra or Cialis seemed to work anymore and switched to Levitra. I also buy it from ADC and have a script filled from CVS. I can't tell the difference between the two drug sources. They both work the same.
Posted 9/27/2009 8:53 PM (GMT 0)
I would like to add the we, men, are at fault here. Particularly when Sonny related the story of the breast cancer survivor.
If men were more vocal, and responded to these issues as a group things would likely be different.
Posted 9/29/2009 1:40 AM (GMT 0)
Sonny,

Walmart actually sells a pill cutter for less than $4. The ADC pills cost about $.60 or less including frt. You can also buy Levitra, but Cialis requires that you use them outside the US. ( they have you sign a paper). Most doctors prescribe 50 mg of Viagara so splitting them in half is adequate.

Also, most urologists are fairly liberal with samples, so you can usually pick up some freebies.
Posted 9/29/2009 1:47 AM (GMT 0)
GL,

Thanks. I have an appt with my local urologist tomorrow to bring him up to speed on my path and the surgery. I plan to hit him up for some samples in the interest of testing them out before I buy the scripts.

Appreciate the heads up,
Posted 9/29/2009 1:54 AM (GMT 0)
I think everyone splits, if you buy online they pretty much only sell the big ones like 100mg Viagra. There is virtually no difference in price.
Posted 9/29/2009 3:15 AM (GMT 0)

My Uro's rehab plan was for 25 mg of Viagra nightly for 3 months.  I bought 100 mg pills and split them x4.  It was for rehab purposes only, that amount would not be effective for anything more.  Buying from ADC was more economical so I continued.  My Uro said at 5 months visit that it wouldn't be of benefit to continue the 25 mg nightly.  I now use 100 mg pill 1 - 2 times per week.  I am getting varied results, but not more than 60%.  I now have a script for Levitra that I will give it a shot.

Sonny, at this time of your recovery I wouldn't recommend skipping any nights if your doc says nightly. 

Dan

Posted 9/29/2009 1:18 PM (GMT 0)
Sonny,

You commented at one point:

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

If this was Cialis then there is no generic available yet in the USA - so that must have been good Ol overpriced Brand Name). I am sure your insurance company hates paying that high price just as much as you do -- hence the meager quantity they will grudgingly give you.

At the above comment point I believe you had only mentioned a Cialis script ... (later on switched convo to Viagra), so the above comment was about Cialis, right.

(For me at 235 days out post op -- still not a lot of action from C or L or V for me ... full strength -- but soldiering on anyways).
Posted 9/29/2009 1:33 PM (GMT 0)
I must have been thinking with the wrong head during this discussion. I'll try to clear up my comments a little.

If I mentioned Cialis and Viagra together is was because my dr gave me a script for each. Cialis - 5mg pills, 1 a day for 30 days and 12 month script. Viagra script for 100mg pills, 8 pills and 12 month script.

Either drug, my insurance company will only allow 5 pills per month and my co-pay would be $60 for each script. They would not allow multiple fillings per month. 5 total pills per month is it not matter what strength I get. That's why I asked the questions about splitting the pills.

Since Walgreens and Publix can fill the script for the Cialis 30 pills @ 5mg for about $130, if I don't involve my insurance company, I figured it had to be generic. Otherwise my copay doesn't make any sense at all.

The out of country pharmacies make more and more sense every time I look at it. I do have a question though; Seems like the ADC site says that Cialis is not for consumption in the US and you have to sign some sort of document attesting to this. What's the deal?

Sorry about the confusion,

Sonny
Posted 9/29/2009 3:53 PM (GMT 0)

Hey Sonny--

As most guys on this site who have availed themselves of ADC will tell you, you just need to tell them that you will be travelling extensively out of the country and need them (Cialis; you said you'd be doing some traveling, remember?)

I have been using 100mg Viagra from ADC for about 4 months now. At first, I was cutting the pills in half with an inexpensive splitter and taking 50mg per night. After consulting with my urologist, as well as my urologist/surgeon, I've moved full speed ahead with 100mg per night with just the slightest of side effects--minor flushing, stuffy head. If your pocketbook permits, I'd try them both. No explanation needed for the ADC Viagra, just the Cialis. Good luck in your pursuit.

                                      Arnie in DE

Posted 10/9/2009 12:00 AM (GMT 0)
I wonder if this part of unpaid medical expenses, can it be a tax deduction? I know that, it doesn't nealy cover the expense at the time, but it may give a little bit of help. I also feel that if enough people appeal then things will change.
Posted 10/9/2009 12:30 AM (GMT 0)

Sonny and all members:

This is a call for all members to fight back.

I think we need to fight the insurance companies about not helping us with the cost of these drugs. We have members in every state and what better way to lobby against this decision of the insurance companies. Lets call our U.S. and state representatives and senators for help. That's what they are elected for. To serve the people. My rep and senator has a town hall meeting every month at the senior center to solve problems and I'm sure there are thousands of PCa patients around this country that have this same problem and we know PCa does not discriminate when it strikes. So I'd bet there are some of our reps that also have PCa. Hope we can get a voice in government to help us. Maybe Senator Chris Dodd for a start.

Please call or email or see your rep if this is a big concern of yours.

Thanks

Huey

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