How best deal with the Realities of Individual-Plan Drug Coverage

December 15, 2010 10:39 PM

How can we get the meds. we need when our individual plan does not cover them?

When our COBRA coverage ended last month we purchased a Blue Cross individual plan because my wife has a pre-existing condition and Blue Cross (Michigan) is the only private insurer who would take us. Today we learned that even with insurance the meds. my wife needs would cost thousands of dollars out-of-pocket.

Two of my wife's meds. are not covered at all and neither is any alternative. We're scrambling to apply for manufacturer assistance but even if we clear all those hoops the meds. will not arrive in time. There are no samples for these so we can't ask her doctor. We submitted our application for Medicaid about four weeks ago and have heard nothing yet. What should we do next?

posted by tangram1 to Health & Fitness (16 answers total)

Best answer: Try local charities. Also, try contacting any charities/organizations related to your wife's condition, if there are any.
posted by unannihilated at 10:45 PM on December 15, 2010

You've probably done this, but check on-line and Canada prices?
posted by ClaudiaCenter at 10:47 PM on December 15, 2010 [1 favorite]

Best answer: Most of the big US pharmacies now have drug discount cards (not insurance but a discount) including some very low prices for common generics. I know Target and Walgreens do this, I think CVS does. Call around, see if they have a plan and how much your wife's drugs would cost. Also check the Costco pharmacy. I'm guessing that it would still be expensive but it is certainly worth a phone call to find out.

Also, try your local free clinic - they would know what more about local and state options for medications.
posted by metahawk at 11:21 PM on December 15, 2010 [1 favorite]

Best answer: Google "free drug card". There's a ton of them. Choose a couple and ask the pharmacy to see which one gives the best discount. I'd also google the name of each drug and see if their web sites have any coupons or deals for signing up. You can also search for "name of drug" + coupon.

Call your doctor and ask if they know of any programs or if the drug reps have given them any free or discount coupons (it's rare but I've gotten lucky so it's worth asking).

A lot of pharmacies price match. Costco is usually cheaper than everyone so find out their price and have your pharmacy call to verify. If you have some money but not enough for a whole script, most pharmacies will fill a partial order and let you pick up the rest later.

I know all this won't solve your problem but I hope it buys you some time until you can figure something out.
posted by stray thoughts at 1:39 AM on December 16, 2010

Best answer: This could be a useless suggestion depending on her condition, but is there an alternative treatment that could replace the prescription?

I had a similar problem with my Rheumatoid arthritis medication. I was taking Enbrel, which costs about $15,000 a year and I had a $3,000 limit on my prescription use. My doctor was able to switch me to a drug called Rituxin. It is administered as an infusion drug at the hospital, so it is considered an inpatient procedure and is not subject to the prescription guidelines.

It still had to be considered medically necessary, which it is, but I got a few chuckles over the fact that the insurance was now paying $30,000 a year for my treatment.
posted by saffry at 4:26 AM on December 16, 2010

Best answer: I'm sorry, this is really crummy. Talk to a pharmacist; they may have some leads. Your doctor may be able to get to the drug companies faster. Call your local United Way and your city; they know who the local funders are. And, as above if there's a non-profit education/advocacy group, contact them. Good luck.
posted by theora55 at 4:55 AM on December 16, 2010 [1 favorite]

Best answer: Don't give up on the idea of talking to your doctor just because you think they don't have samples. Your family isn't the first to have crappy insurance and be affected by this condition, whatever it is, so your doctor or someone at his/her office might have some ideas that you haven't even dreamed up.

Also, does the condition have some kind of advocacy group/nonprofit associated with it? They might be able to help, particularly if it's just short-term while you get set up with the manufacturer assistance.
posted by vytae at 5:09 AM on December 16, 2010

Best answer: Oh, also, get on the phone with the insurance company and keep asking. I also take a medication in a similar price range, and I've had various misinformed people tell me several times that they weren't covered when they actually were -- both at the insurance company and the pharmacy. If someone tells you No, ask to speak to their boss. Keep escalating until you feel really certain that the person you're talking to really knows what they're talking about.
posted by vytae at 5:12 AM on December 16, 2010

I don't have any suggestions for immediate assistance that haven't already been mentioned, but if you do decide to go the Canadian drug route, I can personally recommend Blue Sky Drugs. They're out of Vancouver, and I used them for over two years when I had no health insurance. My medication would have cost nearly $700/mo in the US, but was $164/mo, including shipping, through this company. They have excellent customer service, and I never had any trouble with the medication itself. I faxed my doctor's scripts to them, and then ordered refills online. They always call to confirm they received your order, and I always received exactly what I ordered exactly when they said it would arrive. I have referred several friends to Blue Sky, and they have had similarly good experiences.
The only downside is that shipping does take 1-3 weeks depending on where the supplier is located, but with careful planning this was not an issue for me.
posted by catwoman429 at 5:20 AM on December 16, 2010 [1 favorite]

Best answer: You probably have several options, including some already mentioned, like local charities (our local Kiwanis club has a program for this, as do several local churches) and non-profit organizations that deal with specific conditions. Check with the County you live in, most have a program like this as well, but try not to be too put off by the often-depressing names (like Indigent Assistance, or something equally bleak and antediluvian)

Have you tried Partnership for Prescription Assistance? http://www.pparx.org/ (I found the link on michigan.gov and they seem pretty above board, but I've never worked with them)
posted by metricfuture at 5:25 AM on December 16, 2010

Best answer: Here is a great website: Needymeds.org

They are a central place that can help you find cheap or free medications, disease-based assistance, pharmaceutical company help, referrals to clinics, drug cards etc. All in one place.
posted by chocolatetiara at 6:21 AM on December 16, 2010 [1 favorite]

Response by poster: Man, these are incredible! So much better than we ever expected. Thanks so much, everyone. We're on the phone and web now!
posted by tangram1 at 7:15 AM on December 16, 2010

Best answer: All the drug commercials on TV end with a line: Can't afford your prescriptions? Astrazenica can help.
posted by CathyG at 7:53 AM on December 16, 2010

Response by poster: Thanks, that will teach us not to fast-forward through those things.
posted by tangram1 at 8:50 AM on December 16, 2010

Best answer: Definitely talk to your doctor and explain the situation. Although docs and drug reps aren't legally allowed to be quite as chummy now as they were in the past, your doc may be able to pull some strings.
posted by radioamy at 8:50 AM on December 16, 2010

Response by poster: My doctor did indeed come up with a solution. We'll use these other suggestions for our other meds. Yeah MeFi!
posted by tangram1 at 11:21 AM on December 16, 2010