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Viagra/Cialis-- Insurance Denial

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Posted 7/20/2010 4:11 AM (GMT 0)
Seems that most men are only allowed 6 (max) tablets a month.  Insurance companies deem this a "recreational drug" even though its for therapy for post surgery PC patients or patients with ED due to PC treatments.  I am wondering what your coverage is for these meds? If not accepted, were you able to talk to your insurance company and try to get an explanation?  What was their response?  The amount of $$ needed to do therapy per month with viagra or cialis is astronomical.  Why will an insurance company pay for physical therapy, MRIs and x-rays for other issues but not ED meds needed to perserve the use of an organ?  
Posted 7/20/2010 6:14 AM (GMT 0)
The blunt answer is that insurance won't pay for something if they can come up with an excuse to get out of it. If you order generic from overseas using an online pharmacy (discussed many times in this forum) you can get a year's supply for a modest amount. Different looking pills, same drugs, work exactly the same as the expensive US version for a fraction of the price.
Posted 7/20/2010 10:08 AM (GMT 0)
The problem is this: You did not have an injury to your Penis, had you say had an accident and suffered damage there then they would have covered your Rx

Mine only covers only a few month but that comes with a $40 co-payment, so it is cheaper for me to just go Generic or SAMPLES when I need them

If your Ins co pays for 6 x 100mg pills then you have 12 x 50mg pills that you need for therapy. Ask your Dr for a few samples , if you get 4 pills which is not a big deal for Dr's then you have 8x50mg more pills. Now your total is up to 20 daily doses.

Mine also gave me 4 x 20mg Cialis which lasts for 3 days each pill so there is another 12 days of meds. Mine also gave me some 20mg of Levitra, those are 20mg, split them and you get another 8 days ( 4 x 10mg)

It really pays to ask for samples, I ended up with 40 days of daily ED oral drug and only paid my one Copayment. NEVER leave your Dr. office without samples, its like leaving $50 on the waiting room magazine rack

If you wish to just buy a 30 day Rx with no Ins some big pharmacy's offer an RX card that knocks 30%-40% off the retail price of the drug.

The first few months of Daily ED drugs is all you likely will need so you just need to come up with a 60 day plan of coverage. Its very easy to do as I described above and only pay for 2 months co-pays and a couple of Dr visits.
Posted 7/20/2010 1:37 PM (GMT 0)
My insurance won't pay anything towards a Viagra prescription.

I am not too unhappy with them. They paid all but $650 of my $40,000+ hospital bill.

Dan
Posted 7/20/2010 2:10 PM (GMT 0)
My insurance does not conver the pills either. Thank you BCBS!

Cajun Jeff
Posted 7/20/2010 2:12 PM (GMT 0)
My ins. pays for 8 cialis pills (regardless of size) per month. My use is 5mg / day, so got some samples and the "free" month of 5mg. After those ran out I got the doctor to change the Rx to 8 x 20mg. Then I try as best I can to quarter then with a pill cutter. A very inexact science for someone as clumsy as me. For now my deductable is done, but come January they will be real expensive.
Posted 7/20/2010 3:27 PM (GMT 0)
just for another viewpoint, my company's insurance does NOT cover ED drugs, but since i was in the healing process, i'm getting a 2 year waver, and they have been paying 80-something % on my daily Cialis script. i am starting to get previous function, now that i am at 18 month post-surgery point, and am, shall we say, cautiously optimistic that i will not be needing the pills come january when the waver runs out.
bob
Posted 7/20/2010 4:08 PM (GMT 0)
Mr Gimpy-- Do insurance companies approve Viagra, Cialis and Levitra all at the same time? I am going to look into this.

Bob- That is great news about getting function back and hopeful for us. Who is your insurance company? Did you have to appeal or did they willingly agree to pay 80%?
Posted 7/20/2010 4:14 PM (GMT 0)
Hi all - interesting topic. My insurance company (Humana) will pay for 6 ED pills per month, regardless of the brand. If I already received 6 viagra, then I have to wait a month to get 6 Levitra, for example. I was originally prescribed Viagra, but the doc gave me some Levitra samples which gave a better response. I had to wait three weeks before insurance would pay for the Levitra.
Posted 7/20/2010 4:24 PM (GMT 0)
the company uses some smallish administrators out of Oklahoma City. they started using a system of having a Case Manager overseeing your major situation, and this turned out to be great deal for me, because she has gone to bat for me and gotten things approved, when i wasn't sure my appeal would have accomplished anything. the ED drugs are one example, another is that she helped convince the insurance to cover the cost of my "therapy" (vacuum erection device) . i had doctor's prescriptions for these things, so this got it okayed. so i know i kinda won this part of the game, and there's a lot of variation from company to company..
bob
Posted 7/20/2010 5:39 PM (GMT 0)
My ins. will not pay for multiple ED drugs in the same month - have to wait for the 30 days to pass before I could have a change.
Posted 7/20/2010 5:45 PM (GMT 0)
I am about to have the surgery and will have to do the ED therapy.  Can you tell me if you will know after one dose if it's doing it's job or does it take several doses for the medication to kick in?  Never thought about the expense of these little pills.
Posted 7/20/2010 6:49 PM (GMT 0)
Hi Minn,

You will not see the ED drugs doing their job right after surgery. They are designed to increase blood flow to the area that needs healing. You may experience a nocturnal erection

Remember the post op daily ED therapy primary goal is not to get an erection suitable for intercourse, if that works out that way them great but that not the idea

Hi Hope and Prayer, I have not tried to submit multiple ED brands to my Ins company.
Posted 7/20/2010 11:18 PM (GMT 0)
Minn,
One way to deal with the pills on insurance is to get the Rx as soon as possible for whatever the policy will pay, and ask for a sample of the different types to test.
I'm taking Cialis just for bloodflow - with the extent of my surgery I don't have to worry about a random erection. If I change it would be because of side effects.
So in my case, I expect nothing other than good circulation
Posted 7/20/2010 11:34 PM (GMT 0)
I have been getting 20mg of Cialis and cutting them in two. My carrier only covers 8 per month. Also, ask the urologist for samples...

Luckily, I don't really need then since my hormone therapy has faded. While I was on HT, there was no sex. I was shut down. Seeing as how I had surgery and was on HT by month three, I had begun to think that I would never be able again. but things came right back this year ~ woo-hoo...

I have to say I love the "off" cycles of intermittent HT better...:-)

Tony
Posted 7/20/2010 11:45 PM (GMT 0)
I had to jump through a lot of hoops for Viagra, that started with denial of coverage, and my ordering the medication through AllDayChemist instead. Then insurance changed to to "we'll only cover 8 pills a month" and finally they approved an exception for 90 pills per quarter as long as I need them. What convinced them was the letter of medical necessity from my surgeon, the head of the robotic unit at Ohio State's James Cancer Center. My regular urologist was impressed and asked for a copy of it so he could use it for other patients. Is there a way to post documents to emails here? Couldn't figure out a way--would be happy to share it if it helps others.

Incidentally, this was all fine last year when my surgery costs caused me to hit my deductible and out of pocket maximum limits, so the medication ended up being free. This year our deductible went up and our out of pocket max more than doubled, so even though insurance technically covers it, I went back to ordering from AllDayChemist. $100 for 120 pills through them vs. $1000 for 90 pills through insurance (which is offset considerably provided you hit the $2500 deductible).

Posted 7/21/2010 4:04 PM (GMT 0)
Congrats on your ZERO PSA! Thanks for the info. I am going to see if we can get letters from ED dr and surgeon. BF had no success with Viagra and pump as well. Tried the Trimix but hurt due to reaction from aprostodil. I think Muse has aprostadil. He is currently using Super Bimix at 45 units with good results. I wonder if it will work for you.
Posted 7/23/2010 2:22 AM (GMT 0)
Hope and Prayer--forgot to update my signature (thanks for the suggestion!). Am actually using bimix now with good results. MUSE, caverject and trimix do all have alprostadil and hurt me. Some guys aren't bothered by it.
Posted 7/23/2010 7:08 AM (GMT 0)
Dear mountain top high and all others.

As a general rule most documents can be inserted into sites such as this with relative ease. Go open the document and then "SAVE AS" a text file for Windows machines which is an FILE function.

Once the file is saved as text you can copy and paste it here in the text box. You may loose some details and sometimes things will need cleaned up a little but not much more work is required than that.

Next Item. ED drugs and the VA. If you are receiving VA care already, a prescription shown to your VA Dr, should get you about 6 Levitra each 12 weeks for either $6 or free.

So between free samples, the VA, insurance companies sometimes and your charge card for All Day Chemist and "Double Pill Offers", most of us should be able to find reasonably priced options we can live with.

I don't know about you but I do know about us and our sexual health is worth the trouble.

Jim
Posted 7/23/2010 11:40 AM (GMT 0)
Hope, our insurance company covers 4 Viagra each month with an out-of-pocket of $20. That's all they will cover. Sometimes, when John visited his urologist, he'd ask for Viagra and Dr. B would give him some sample packs. Otherwise, we order Manly through All Day Chemist.
Posted 7/23/2010 12:38 PM (GMT 0)
My insurance does not cover the pills. ADC is my loaction for the pills. At the Uro office I usually get a couple of sample packs.


Cajun Jeff
Posted 7/23/2010 1:10 PM (GMT 0)
maltrado and mountain top high, :

posting doctors letters here is allowed, with the provision that you have permission of the writer to post it. Check out Rule 9 and 10, to make sure you aren't violating copyright and permissions rules first, ok? Any data is helpful, if it is approved for worldwide posting by the originator. Sorry, but Peter's just that way about things....lol smilewinkgrin

9. No posts of copyrighted material. Information copyrighted or owned by any individual or entity other than the person posting should not be posted on the message boards without the consent of the owner.

10. No posts of lengthy articles. Sharing information is allowed, but the forums are not to be used to publish articles. It is an improper use of critical forum resources.

tongue
Posted 7/23/2010 2:08 PM (GMT 0)
The pills never worked well for me, but I also had the insurance issue. Like others here, I went to ADC by mail order and at least the insurance problem was solved. I paid out of pocket, but pretty cheap and the same quality as the prescription pills.  Same headaches and stuffy nose too :-(
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