Insurance coverage Hasn’t Been Masking Drug They Ought to Have Been, Will not Reimburse Me

By | October 26, 2018

Hiya! I will preserve this as transient as attainable. I’ve been prescribed HCG (bought beneath many model names, together with Pregnyl and Novarel) and have been taking it for a few 12 months. This drug is explicitly excluded from my insurance coverage firm (HealthNet)’s formulary. When my physician despatched it to my regular pharmacy, consequently, they have been going to fill it as Novarel, which was going to price $4,765 out of pocket. We lastly discovered an area compounding/specialty pharmacy who would fill it as Pregnyl, which price $135 out of pocket. We appealed for prior authorization, overrides, my physician and I jumped by way of all of the hoops to see if my insurance coverage firm would cowl it. They’d not, and advised us that they don’t, beneath any circumstances, cowl Pregnyl or any type of HCG. So I have been paying out of pocket, $135 a month, since final December. There’s at present a scarcity on Pregnyl. My physician licensed the pharmacy to fill the prescription as Novarel as a substitute. After this, my physician begins getting faxes from a distinct pharmacy. It seems that HealthNet will cowl Novarel, 100%, if I get it from their pharmacy – let’s put apart the truth that my data being despatched to this pharmacy with out the information or consent of me or my physician is a serious HIPAA violation, for the sake of this thread. The truth that they might cowl it beneath these circumstances was by no means defined to us. In reality we’ve, in writing from final 12 months, that they NEVER cowl it, regardless of the place I’m going, as a result of it is excluded from the formulary. Clearly this was not the case and I have been paying out of pocket for no motive. Not solely will HealthNet not reimburse me for the $1500 or in order that I’ve spent on treatment for the reason that starting of final December, the customer support rep I spoke to closely implied that if I raised too massive of a stink about it, they might decline to cowl the Novarel sooner or later. To be clear, the rep didn’t threaten me, she cautioned me that she had seen them do this in a really “I am not telling you this, however” tone of voice. What recourse, if any, do I’ve? I am glad they’re protecting my treatment now, however boy I actually might have used that $1500. submitted by /u/Afro-Pope [link] [comments]