New insurance forcing me to switch birth control
May 11, 2021 5:42 PM   Subscribe

I love my current (brand name) oral contraceptive. I've been on it for 5+ years. Now, my new insurance is telling me that I need to switch to a completely different type of OC (with a completely different formulation of active ingredients) or engage in what will surely be a lengthy paperwork battle.

I have new insurance, and just received a letter in the mail telling me that I will not be able to refill my current oral contraceptive, and that I first need to switch to a "preferred first-line step therapy" which is a completely different type of oral contraceptive with completely different formulation. Otherwise, my prescribing physician needs to prove that my originally prescribed medication is the "only effective treatment for my condition," or I need to provide evidence that I have previously tried a first line medication that did not work.

This is difficult, because I've been on my current contraceptive for over 5 years, and I've had multiple OBGYNs over the years. My current and previous obgyns have only ever prescribed me this OC. I'm not even sure I can obtain evidence of the MANY, MANY other OC brands that I attempted to take in my 20s ....because that was over 10 years ago. I remember them each causing various issues -- cramping, depression/anxiety, excessive bleeding, breakthrough bleeding, headaches, etc. I finally found one that worked for me, and now they want to take it away because the insurance has decided that they know what's best for my body.

No part of me wants to switch to a new pill in my mid-30s and have to go through the selection process again. It was hard enough in my 20s. Besides rage, what productive steps can I take to fight this with my insurance company?
posted by Anonymouse1618 to Health & Fitness (13 answers total) 6 users marked this as a favorite
I'd start with contacting your current OBGYN and asking for their help. They likely have experience with this type of insurance nonsense and can advise you about how to fight it and/or can advocate on your behalf with the insurance company.
posted by theotherdurassister at 5:48 PM on May 11, 2021 [34 favorites]

I go through this type of stuff with some of my current meds every year. It freaked me out the first few times, as the meds they wanted me to take instead were completely useless to me. The OBGYN's office likely has someone on staff who knows all the ins and outs of negotiating with the insurance company and getting all the paperwork settled. Talk to the front desk staff and get that person's name and contact info. Put them to work for you.
posted by gemmy at 6:17 PM on May 11, 2021 [3 favorites]

Best answer: My insurance did this to me a few years ago with asthma medication, and there was not any way to fight it, despite the extremely nontrivial efforts of my specialist doctor's office (just like, reams and reams of paperwork, hours on the phone, etc.). In the end I did have to try four different asthma medicines for a few weeks each before they would continue to cover the medicine I'd been on since childhood. This basically meant that for several months I couldn't really function, which was neat.

As an added bonus, my special dispensation to keep taking the same medicine I've been on for 26 years expires annually! So every August, I spend 8-10 hours on the phone with the insurance company explaining that I already did the step therapy, that it negatively impacted my quality of life, and that there is no reason to expect that this time will be different. Then my doctor's office gets to spend another 8-10 hours on the phone with them repeating exactly what I told them. Sometimes it circles back around to me again. I can never leave teaching, because if I didn't have summers off, how would I have enough time in August to deal with my insurance company.

Insurance is fucked up and evil. Part of my fury was that the medications they made me try cost the same amount as the one I take (~$400 a month, so not really an amount I could just eat!), they just don't have special sweetheart deals with the company that makes it.

One thing that's worth looking into is whether there are deals from the manufacturer (since it's a brand name) or GoodRx coupons that might make it possible to just skip insurance altogether. It's obviously infuriating to have to pay out of pocket for something that ought to be covered by insurance, but if it won't be too big a financial hit, IMO it might be worth it.
posted by goodbyewaffles at 6:22 PM on May 11, 2021 [24 favorites]

Definitely ask the doctor for help. This is probably routine for them, and there are probably people on staff who have this as part of their job description.
posted by amtho at 6:27 PM on May 11, 2021

Best answer: This kind of thing is annoying, but happens all the time. I'd ask the doctor to fill out a prior authorization form. Usually the pharmacy can do this, and the doctor signs off on it. You don't need to scrounge up records to prove that the other medications didn't work - all you have to do is tell your doctor which ones you tried, which ones didn't work, and generally that is enough to get approval.
posted by gemutlichkeit at 7:04 PM on May 11, 2021

My best advice is either have your doctor prescribe that exact one...

Or use GoodRx to find the cheapest out-of-pocket place to buy it from, with the caveat that it WILL NOT COUNT toward your deductible. (But if it's cheap enough that it will never really contribute to your deductible much, esp. if you have a high deductible plan, then it may be worth it to use out-of-pocket money.)
posted by kschang at 7:14 PM on May 11, 2021 [2 favorites]

You might also call Planned Parenthood for advice. They'll probably have similar advice to what's been offered here, but they might have specific suggestions for wording when you speak with your doctor. Or specific low-cost options for finding your medication cheaply if it comes to that.
posted by Umami Dearest at 7:18 PM on May 11, 2021 [1 favorite]

Mr. BlahLaLa just went through something similar (though obviously not for birth control pills). His doc wrote that his specific prescription was "medically necessary" -- those were the exact words -- and voila it was covered.
posted by BlahLaLa at 7:46 PM on May 11, 2021 [2 favorites]

I definitely recommend checking GoodRx before spending too much energy on your insurance. Sometimes insurance is really necessary, but sometimes the GoodRx price is better than the out of pocket with insurance, especially if you can do 90 day refills.

It only takes a few minutes to check and doesn't require creating an account or anything, just go to the website, find the medication, type in your zip code, and it will give you a price from various pharmacies in your area.
posted by wierdo at 7:47 PM on May 11, 2021

Best answer: Have you looked at getting your pills online? I had trouble finding a new obgyn last summer in time to get a renewal on my pills, and I was able to get a different generic of the same formula pill from the Pill Club. I filled out questions on their website, put in my insurance information, and the new pills were covered. They sent me 16 free packs. I think it would be worth looking into before going through a lot of hassle to get the same pills the traditional route. I think I googled "birth control pills online" to find the website I used.
posted by DEiBnL13 at 8:19 PM on May 11, 2021 [1 favorite]

Have you asked your pharmacist how much the contraceptive would cost if you just paid for it out of pocket? Never ideal, but the cost might be low enough to want to forgo the insurance fight.
posted by gregr at 7:08 AM on May 12, 2021 [1 favorite]

Pay out of pocket for three months of your current pill while you deal with the insurance company. "Dealing with the insurance company" may include having your doctor prescribe the pill you don't like; you pretend to take it and tell the doctor it's causing you problems.
posted by metasarah at 8:26 AM on May 12, 2021 [2 favorites]

For what it's worth, Costco is cheaper by a couple bucks with no insurance for my only prescription (Synthroid), which Aetna said I was only allowed to fill at Costco twice. Seriously wtf.
posted by Glinn at 3:59 PM on May 12, 2021

« Older Get the OLED out   |   Is 450 words too long for an email? Newer »
This thread is closed to new comments.