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What to do if IBS medication is not in insurance drug formulary

Linzess insurance

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#1 APR

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Posted 08 November 2018 - 04:57 PM

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After having a terrible time with IBS-C, I've finally gotten some relief with Linzess [in addition to a daily dose of Miralax].  It's far from perfect, as Linzess just gives me liquid D for 1.5 hours, but my IBS has progressed to the point that I will never have a BM [aside from a little bit of D once in a while].  Linzess is the only thing that has significantly helped [probably due to a medication interaction, Amitiza didn't do anything].

 

The problem I have is that due to my income, I might end up on a Healthy Michigan insurance policy next year [Healthy Michigan is Michigan's version of expanded Medicaid].  Currently I get a significant subsidy and reduced out-of-pocket costs to purchase a policy off of the health exchange [what some people call an "Obamacare policy"].  The PPO that I currently have that I purchased off of the health exchange covers Linzess, but Healthy Michigan [Medicaid] policies do not include Linzess in the drug formulary.

 

The State of Michigan has private insurance companies handle the administration of Healthy Michigan/Medicaid.  The coverage is the same regardless of what insurance companies' Healthy Michigan policy you choose, but there is some variation as far as which treatment providers you can go to.  There is potentially a little variation in which prescription medications are on their drug formulary, but I haven't found any Healthy Michigan policy that has Linzess on their drug formulary.  In fact, I have only found one policy that has Amitiza on their drug formulary [and none have Trulance on their drug formulary].

 

So I guess my question is:  how hard is it to get an exception, so that they will cover Linzess even though it isn't on the drug formulary?  Has anyone tried to get an exception to get coverage for an IBS medication that is not on your insurance policy's drug formulary?  What was the outcome?

 

I can't believe that most of these Healthy Michigan policies have virtually no IBS medications on their drug formulary (i.e., Vibersi).



#2 annie7

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Posted 08 November 2018 - 05:19 PM

you could try having your doc write an appeal to the insurance  company telling them that linzess is the only med that works for you and that it's a medical necessity and maybe then they will decide to cover it.

 

that's what i did back in the day when zelnorm was available.  my insurance company, blue care network, didn't cover zelnorm so my doc wrote an appeal and then they finally agreed to cover it. 

 

good luck.


these are just my own thoughts. for expert medical advice please contact a health care professional.


#3 APR

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Posted 09 November 2018 - 03:06 PM

Thanks for the advice.

I really don't trust HMOs in general [though when it comes to prescription meds, insurance companies can give you a hard time even if you have a PPO].

 

Assuming I don't end up on expanded Medicaid/Healthy Michigan, I am going to have to pay $50 a month more next year to keep my current PPO insurance policy.  In theory, the federal subsidy is supposed to limit the percentage of my income that I have to spend on insurance premiums, but the subsidy you get is based on the second cheapest silver policy on the health exchange.  The reality is that not all insurance policy premiums increase by the same percentage [and certainly they don't all increase by the same dollar amount].  People with medical conditions tend to prefer PPOs to HMOs [for good reasons], so PPO premiums have been increasing more than HMO premiums.  Of course, the second cheapest silver policy is an HMO.  The net result is that I [and others who get subsidies] have to pay more and more to keep my PPO policy.  There's not much I can do if I want a PPO.  I already have the cheapest silver policy that is a PPO [and although multiple insurance companies offer policies on the health exchange in Michigan, starting in 2017 or 2018, only one of those companies offers PPOs].

I made the mistake in 2017 of getting an EPO that was cheaper than my PPO, and I got totally screwed.  They ended up not paying for a treatment I need [unrelated to IBS] and I was stuck with huge out of pocket costs.  This was in spite of the fact that according to their provider directory, the treatment provider was in-network.

I just want to make sure that Healthy Michigan is going to actually cover Linzess before I sign up.  I won't have to pay $300 a month in insurance premiums with Healthy Michigan, but that isn't an improvement if I'm stuck paying more than $300 a month for Linzess out-of-pocket.

 

Note that I'm still much better off than before the ACA: having a pre-existing condition, no subsidy, and no expanded Medicaid to fall back on.


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#4 stanislavski66

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Posted 09 November 2018 - 04:47 PM

I am delighted to hear of your good experiences with the ACA (and sorry that you may have to go off it) It was a life-saver for me when it kicked in in 2014. I got a decent subsidy and was able to have excellent insurance. I am now on Medicare and have chosen to avail myself of a Medicare Advantage plan (United Health) While there is no premium to pay, the back-end costs can be a lot steeper than on the ACA. I just can't believe all the negative press the ACA has gotten, given that it has helped so many millions. I live in FL, btw, so there would have been no expanded Medicaid to fall back on. Medicare has one huge disadvantage: YOU'RE OLD! :-) 



#5 flossy

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Posted 09 November 2018 - 05:10 PM

After having a terrible time with IBS-C, I've finally gotten some relief with Linzess [in addition to a daily dose of Miralax].  It's far from perfect, as Linzess just gives me liquid D for 1.5 hours, but my IBS has progressed to the point that I will never have a BM [aside from a little bit of D once in a while].  Linzess is the only thing that has significantly helped [probably due to a medication interaction, Amitiza didn't do anything].

 

The problem I have is that due to my income, I might end up on a Healthy Michigan insurance policy next year [Healthy Michigan is Michigan's version of expanded Medicaid].  Currently I get a significant subsidy and reduced out-of-pocket costs to purchase a policy off of the health exchange [what some people call an "Obamacare policy"].  The PPO that I currently have that I purchased off of the health exchange covers Linzess, but Healthy Michigan [Medicaid] policies do not include Linzess in the drug formulary.

 

The State of Michigan has private insurance companies handle the administration of Healthy Michigan/Medicaid.  The coverage is the same regardless of what insurance companies' Healthy Michigan policy you choose, but there is some variation as far as which treatment providers you can go to.  There is potentially a little variation in which prescription medications are on their drug formulary, but I haven't found any Healthy Michigan policy that has Linzess on their drug formulary.  In fact, I have only found one policy that has Amitiza on their drug formulary [and none have Trulance on their drug formulary].

 

So I guess my question is:  how hard is it to get an exception, so that they will cover Linzess even though it isn't on the drug formulary?  Has anyone tried to get an exception to get coverage for an IBS medication that is not on your insurance policy's drug formulary?  What was the outcome?

 

I can't believe that most of these Healthy Michigan policies have virtually no IBS medications on their drug formulary (i.e., Vibersi).

 

Hi APR -

 

I was on Medicaid for awhile and yes, they do not cover some prescription meds. As soon as they say you (or your doc) needs prior authorization? You can pretty much count on not getting it. It's a systematic way of saying no; giving you the run-around.

 

Have you tried Intestinal Formula # 1? I've been on it over 3 years now and love it. You don't need a prescription for it and it is an all-natural herbal formula. (And it doesn't give me D either.)

 

Read when you have the time:

 

http://www.ibsgroup....-can-recommend/

 

Good luck and keep us posted!



#6 APR

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Posted 09 November 2018 - 06:29 PM

I am delighted to hear of your good experiences with the ACA (and sorry that you may have to go off it) It was a life-saver for me when it kicked in in 2014. I got a decent subsidy and was able to have excellent insurance. I am now on Medicare and have chosen to avail myself of a Medicare Advantage plan (United Health) While there is no premium to pay, the back-end costs can be a lot steeper than on the ACA. I just can't believe all the negative press the ACA has gotten, given that it has helped so many millions. I live in FL, btw, so there would have been no expanded Medicaid to fall back on. Medicare has one huge disadvantage: YOU'RE OLD! :-) f

 

I'm sure that most people here don't want to get into a political debate about the ACA, but I never could understand why some lower income people vote for politicians who refuse to expand Medicaid.  I have some issues with Medicaid (i.e., only a small percentage of doctors are willing to take it because the reimbursement amounts for various treatments is lower than with private insurance or even Medicare), but for people below or slightly above the poverty line, private insurance is going to be too expensive and being on Medicaid is a vast improvement over being uninsured and having virtually no access to medical care, outside of an ER.

 

As you allude to, Medicare has significant out-of-pocket costs, at least if you don't either get a Medicare Advantage plan or purchase a Medicare supplemental policy.  Medicare Advantage would appear to be the cheaper way to go, but my concerns about HMOs also generally apply to Medicare Advantage policies.

I am trying to figure out what to do as far as my current situation goes, but don't get me wrong:  the ACA has been a big help to me.  It helped me as far as the subsidy and reduced out-of-pocket costs, as well as prohibiting insurance companies from discriminating based on "pre-existing conditions" [like most people in this group, I have at least a couple of medical issues that could be defined as "pre-existing conditions"].



#7 APR

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Posted 13 November 2018 - 06:06 AM

 

Hi APR -

 

I was on Medicaid for awhile and yes, they do not cover some prescription meds. As soon as they say you (or your doc) needs prior authorization? You can pretty much count on not getting it. It's a systematic way of saying no; giving you the run-around.

 

Have you tried Intestinal Formula # 1? I've been on it over 3 years now and love it. You don't need a prescription for it and it is an all-natural herbal formula. (And it doesn't give me D either.)

 

Read when you have the time:

 

http://www.ibsgroup....-can-recommend/

 

Good luck and keep us posted!

 

Flossy, thanks for the info. and sorry I didn't reply to your comments sooner.

 

I am sensitive to stimulant laxatives.  I'm not sure if Intestinal Formula #1 that you are referring to has something like that or not.  After a while, those senna based laxatives stopped working, but even when they were working I found that they actually aggravated some of my IBS Symptoms [gut pain, in particular].

 

I will check it out.

 

Ridiculous that any insurance--whether Medicaid or not--would not cover a medication you really need.  I can understand step therapy:  try this cheaper medication that is generally just as effective, and if it doesn't work well or the side effects are intolerable, then they'll be willing to cover the medication in question.  But most of the insurance company Healthy Michigan/Medicaid policies don't cover any of these type of meds--and the one that did only covered Amitiza.  One would think that you could get an exception for Linzess if Amitiza is ineffective as a result of a medication interaction.  That should be the case if Amitiza is ineffective, regardless of the reason, but it is easier to document that this medication combination is an issue and that you are on the other medication in question.

 

I think there is a mentality that IBS just isn't that serious of a medical problem, so you really don't need the medication that badly.  I would be surprised if they refuse to cover any medications for UC or Crohns disease.



#8 flossy

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Posted 13 November 2018 - 04:19 PM

Here is the list of ingredients in I.F. # 1 (click on below link to view):

 

https://images-na.ss...511J6MvLJfL.jpg

 

Good luck & keep us posted!



#9 BeondFrustrated

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Posted 19 November 2018 - 09:48 AM

I have bottles and bottles of Linzess unopened, wish I could get them to you somehow.





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