Insurance Cancels Allergy Drug Coverage

September 28, 2008 8:42 PM

My insurance company (Blue Cross/Shield MA) is dropping all prescription drug benefits for allergy drugs in favor of over-the-counter medicine like Claritin. I have serious allergies and take Alegra 180. What can I do?

My insurance company (Blue Cross/Shield MA) is dropping all prescription drug benefits for allergy drugs in favor of over-the-counter medicine like Claritin. The rationale being that all allergy symptoms can be treated by this class of drug.

I have very serious allergies and take Alegra 180. I've tried Claritin, Zyrtec, and a variety of other drugs and finally settled on the serious prescription allergy drug I have been on for the last 5 years.

What can I do now that my insurance seems to be revoking all coverage?

posted by morallybass to health & fitness (20 comments total)

Maybe find out if there is a way to petition for an exception to their new policy? Maybe if you provide them with a letter from your doctor testifying to what you wrote here?
posted by dcjd at 8:55 PM on September 28, 2008

If Alegra 180 can be prescribed for another use other than allergies, ask your doctor to prescribe it for that other reason and have him use whatever insurance code is used when he submits his bill that relates to the alternate use. If no alternate use, find out if there is an over the counter version and increase your OTC dose to match your former prescription dose. Or, failing all that, set up or allocate money into a flex pre-tax spending plan and pay for it yourself.

Also, not knowing BC policy, there may be some appeal process that you can try.
posted by JohnnyGunn at 8:59 PM on September 28, 2008

Most companies allow doctors to petition on behalf of their patients for exceptions to policies like this. Call your insurance company and ask what the procedure is for doing so.
posted by decathecting at 9:02 PM on September 28, 2008

If you are forced to buy it for yourself, it seems like it's way cheaper in Canada (where it's OTC).
posted by IvyMike at 9:03 PM on September 28, 2008

Allegra isn't OTC in the US yet. But Zyrtec (I think) and Claritin are, and I wouldn't be entirely suprised if Allegra goes that way soon. Does anyone know where to look up if there's a petition in progress to move Allegra to OTC?

You're not the only one who is frustrated by this problem.. here's an article discussing it from when Claritin first went OTC: here.

Is Blue Cross/Shield cutting off all allergy meds, or only ones in the same class as Claritin/Zyrtec? If it's not all meds, have you tried some of the other possibilities (nasal sprays, eyedrops, etc)? The linked article gives a few suggestions:
"If for some reason a cash-strapped Allegra user can't take Claritin, Humana recommends he or she consult a doctor about one of the following inhaled corticosteroid allergy medications that are more affordable and on Level Two of its formulary: Flonase, Nasacort, Nasonex, Rhincort or Vancenase."

Those are just the suggestions from one particular insurance company; personally, I find Patanol (eyedrops, may be called Pataday these days) does wonders not just for my eye symptoms but also for general sinus symptoms too.

If it *is* all meds, then I'd go dcjd's route. I'd call Blue Cross personally though; they're notorious for making providers wait forever on the phone. And of course get names of whomever you speak with.
posted by nat at 9:10 PM on September 28, 2008

From the MA BC/BS site:

Your doctor may request an exception from our Clinical Pharmacy Department to provide coverage for a non-covered drug when medically necessary. If approved, the drug will require the highest level co-payment. If the request is not approved, you will remain responsible for the full cost of the prescription. You may use our standard member appeals process to request further review.

So call them and find out what the process is. Or, your doctor may already have experience with getting an exception for a non-covered drug.
posted by weebil at 9:14 PM on September 28, 2008

Hi! I have Blue Cross PPO here in California, and I'm in the same boat you were.

There are several prescription-level anti-allergy medications you'll still be able to get via your GP/pharmacist, but unfortunately Allegra will be difficult if possible at all.

If your MD is willing to write a letter to your insurer attesting that you've tried other things and Allegra was the only thing that worked, they may cover it - that worked for a colleague of mine who shares my GP and allergies.

The same MD, however, gave me a scrip for nasal steroid sprays that worked far better than Claritin and just as well as Allegra.

Good luck!
posted by luriete at 9:51 PM on September 28, 2008

Check if you insurance will cover the generic version of Allegra with the generic name fexofenadine. When generics are available, often insurance companies will refuse to cover the branded drug but allow the generic drug.

If nothing else, you can buy the generic yourself at about $1.80 per day, less than a cup of coffee.
posted by JackFlash at 10:43 PM on September 28, 2008

I, too, am a committed Allegra user. While I haven't been forced to change to something OTC like Claritin, my insurance company sends me letters suggesting it all the time. Grrr. . . anyway, I just want to second what Jack Flash says. I take the generic fexofenadine and while it's still covered by my insurance, it would be fairly cheap to buy if I had to - not significantly more than the OTC options.
posted by katie at 3:41 AM on September 29, 2008

Check if you insurance will cover the generic version of Allegra with the generic name fexofenadine.

I know for a fact (that is, I checked the non-covered drug list for BCBS-MA a couple of weeks ago and then called to check because it's odd that a generic isn't covered by a plan) that fexofenadine is on the non-covered drug list. I'm a broker in MA and one of our clients was concerned about BCBS's non-covered drug list when making a switch from another MA carrier to BCBS. Looking at the number of non-covered drugs on a typical BCBS client's Rx paid claims list, it's clear that exceptions are very common. Talk to your doctor (actually, you'll probably only have to talk to the office) to get the exception, as weebil noted above.
posted by MarkAnd at 5:11 AM on September 29, 2008 [1 favorite]

Usually exception letters are possible, if that's the only thing that works. Your doctor will know if the generic does work as well on most people.

The only thing that works for me is Zyrtec, and the first couple of months after it went OTC the brand name was 1$ a pill. Then the generic hit the market, and I think two bottles of 45 runs about 6 or 7$ in a box at Sam's Club. So there may be hope that the situation will improve shortly. The deductible was 50$ a month, so this worked out to be a good deal. Eventually.
posted by unrepentanthippie at 6:55 AM on September 29, 2008

you should almost certainly be able to have your doc get an exception. i've had to do this for singulair in the past.

if not, get it from canada. i have had good experience with canadapharmacy.com.
posted by misanthropicsarah at 7:30 AM on September 29, 2008

I've got Blue Cross in PA. They didn't drop coverage of Allegra-D, but they did push it up a $$ tier, even though there's no generic equiv. Call your doctor's office and ask for a letter for your insurance company requesting an exception -- it's a routine request. The doctor's office may charge you $5 or so.
posted by desuetude at 7:38 AM on September 29, 2008

They didn't drop coverage of Allegra-D, but they did push it up a $$ tier, even though there's no generic equiv.


Allegra-D is just a combination of Allegra and pseudoephedrine. You can get generic fexofenadine and purchase pseudoephedrine separately over the counter.
posted by JackFlash at 12:27 PM on September 29, 2008

I hate it when this happens! One question that could potentially get you off the Allegra: have you tried allergy shots? A lot of insurers will pay for the serum and shots. I have been on them for about 2 years and it has significantly helped my allergies. I highly recommend them. They are proven to work and have been around for almost 100 years.
posted by FergieBelle at 12:57 PM on September 29, 2008

Allegra-D is just a combination of Allegra and pseudoephedrine. You can get generic fexofenadine and purchase pseudoephedrine separately over the counter.

Buying 12-hour Sudafed in boxes of 10 or 20 would be considerably more expensive -- most drugstore chains don't bother with generic pseudoephedrine anymore. And "over the counter" is rather a misnomer these days -- I don't think I could even legally buy 60 pills per month. Not to mention that it is ridiculous to have to cobble together medications like this due to the whims of an health insurance provider.
posted by desuetude at 1:10 PM on September 29, 2008

Buying 12-hour Sudafed in boxes of 10 or 20 would be considerably more expensive

If you go to drugstore.com you can see that you can buy a 30-day supply of Allegra-D for $126.

To compare, you can buy a 30-day supply of generic fexofenadine for only $62. You also can then buy a 30-day supply of pseudoephedrine for about $30. The individual generic drugs are much less expensive than the branded combination drug.
posted by JackFlash at 2:08 PM on September 29, 2008

JackFlash, I'm trying desperately to not derail here and possibly failing, but my prescription plan charges $15-25/month for a 60-count bottle of Allegra.

My insurance company (Blue Cross/Shield MA) is dropping all prescription drug benefits for allergy drugs in favor of over-the-counter medicine like Claritin. The rationale being that all allergy symptoms can be treated by this class of drug.

morallybass, maybe I'm being overly optimistic, but i think it's important to stand up to this sort of rationale. I hate to invoke the "slippery slope" argument, but it disturbs me that insurance companies are deeming patient-doctor decisions to be financially wasteful to such an extent that they basically consider send the message that certain, highly arbitrary categories of medications are unnecessary.
posted by desuetude at 5:13 PM on September 29, 2008

Does anyone know where to look up if there's a petition in progress to move Allegra to OTC

I doubt Allegra will go OTC. It's a metabolite of the active ingredient in Seldane, which was taken off the market for interactions contributing to serious heart events.

As to OP's situation: a pharmacy benefit manager claiming that OTC drugs are sufficient for all allergy-control needs is basically saying that it's not important to have nonsedating allergy control. That seems like a pretty amazing usurpation of clinical judgment.
posted by caitlinb at 10:06 AM on October 4, 2008

caitlinb, Claritin is non-sedating.

(It also is utterly, completely ineffectual for large swaths of the allergy-suffering public. I remember reading an article years ago, that discussed how Claritin proved to be very very safe, but it is not more effective than a placebo for something like 80% of seasonal allergy sufferers. I thought in the New Yorker, but I can't find it anywhere.)
posted by desuetude at 1:07 PM on October 4, 2008