OK, so I've tried just about everything and thought maybe it’s time for Lotronex. I found a prescribing physician in my area but after checking my prescription plan I find out it is not covered. Has anyone successfully appealed this and obtained coverage? Is it because I am a male? Thanks.
Lotronex and insurance coverage?
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What insurance do you have if you don't mind me asking?I'm a male and both United Healthcare and Blue Cross/Blue Shield (Minnnesota) covered the drug for me as a male.I remember when BC/BS covered it, 60 .5mg pills were over $500. Insurance covered $470 and I had a copay of $50, so that would make the total cost without insurance like $520 per month...(at the 1mg per day dose).
I have blue cross/shield of N.J. My Rx plan is a $20.00 co pay. I got the "not covered" info from the web site so I will call them and see what gives. Thanks for the feedback.BTW are you still on it and if so how are you doing?
No, I'm not...if you scroll down you can check to see why (insurance reasons...but not the same issues as you, I lost it).But, yeah...online it said they wouldn't cover it. I called a CS rep and he said it was covered and I would have a $50 copay.By chance do you have the mail order option with your plan?If so, what is the pharmacy called?
Grant, I do have the mail order option on my plan. I am not 100% sure who it is through because I never used it but my card say's Rx is handled by CareMark. Thanks for the help.
Pooman, I am a New Jersey native as well...what part of the state are you in.....? I am at the same state of mind as well....tried just about everything worth trying....I guess it would probably be the fact that you are a man with a disease that the Insurance company can get out of its commitment to pay....I have Aetna and they do have it listed on the formulary but I doubt they will cover it if they find out I am a dude.....
Well, here’s the poop (pun intended). After calling CareMark they told me my Doctor has to contact a company called Advance Secure for pre authorization. If that is a no go then he has to send a letter of medical necessity to Horizon. If that doesn’t work then there is an appeal process to go through. So all in all it does sound somewhat encouraging. Right now I am getting over some other problems so when the smoke clears I’ll see what I can do and report back. Noguts, I am in the North East. P.S. I have to laugh at the Lotronex web site test to see if you’re a candidate for the drug. If I had the few symptoms they suggest I don’t think I would really need it.
Pooman-- I've been on lotronex since it was first introduced. no pill coverage until new pill coverage came oujt (medicaid part D). In 2005 I went on AdvantraRX coverage- open enrollment. They covered it in 2006 wiyh only a $20 copay. In January this year no covedrage without a prior authorization, which they won't give. I'm in the appeal process, with Dr's letters. I think the reason no priore authorization was it's only approved by the CDER for women. What a rip off. If the MD says we men need it that shojld be enough. I'll take this through the whole appeal process to U.S. district court if necessary. As an attorney I knowthe procedures. Fraud is in the mess too, since Advantra said theyt only covered it on a "temporary" basis in 2006, without any communication to me. TRhgeir first contact with me was on 1/8/07, so it was too late to go with open enrollment with another company. AARP coverage does not require a pre-approval. I'm 73, so medicate applies. B ill
Could you tell me which Lotronex docs in NJ would agree to perscribe Lotronex for men? (private message is fine) Its gonna take months for me to get it in the UK. I'm prepared to even fly out there and self pay to get some relief as I am going through a bad patch atm and the Ondansetron isn't working very well.Pathlogy came back negative so it looks like I'm just having a bad flareup. It will put me in major debt just to secure a months supply. (Wonders if they might agree to perscribe on docs report and I can get a pharmacy to ship?)Things just arent going my way...
Sorry to hear about your predicament. Have you ever tried Lotronex? It does seem to help many but it is not 100% guaranteed. I would hate to see you go through all that expense and then not have the result your looking for.quote:Originally posted by mr_colt:Could you tell me which Lotronex docs in NJ would agree to perscribe Lotronex for men? (private message is fine) Its gonna take months for me to get it in the UK. I'm prepared to even fly out there and self pay to get some relief as I am going through a bad patch atm and the Ondansetron isn't working very well.Pathlogy came back negative so it looks like I'm just having a bad flareup. It will put me in major debt just to secure a months supply. (Wonders if they might agree to perscribe on docs report and I can get a pharmacy to ship?)Things just arent going my way...
You can have you GP write you a script and purchase it online, although you have to pay full price, US$205 for a bottle of 30 1mg tablets last time I checked.Just do a seach of this forum, its been discussed a few times in the past.
more on insurance coverage for silent and jj-- since Advantra requires "prior authorization" and they refuse to cover it for men, I switched to AARPMedicareRx which uses UnitedHealthCare which requires no "prior". My cost for 60 pills ($500) is $28.00. Secondly for JJ and others, I just returned from Mayo Clinic (Rochester) from another two day workup, including radioisotope "transit" testing. My M.D., Dr. Camilleri is one of the top G.I. docs in the world. He says there is no foreseeable time when FDA will approve lotronex for men, and while he is encouraged about the new research, there's nothing new out there yet. I've gotten three new articles from him on past studies, from the Neurogastroenterology Motility Journal and American Journal of Gastroenterology whic I can mail(not e-mail) if anyone is interested. Bill
This is when I am glad I am female and have insurance. My script is for 120 tabs. If I didnt have insurance that would cost me over $1200/mo.I just dont get how drug companies can get away with this. I also take 2 other meds, and my husband is on a few also. We'd either have to stay sick or be homeless and hungry without insurance.
Bill,Thanks for that interesting piece of info. I have heard of Dr. Camilleri and have read some of his articles in the past, which are excellent. I'm sure Glaxo has at least a thousand better uses for their money than trying to get Lotronex approved in men, so that part comes as no great shock. As for those articles, thanks for your offer to send copies but I'm sure Eric will post some links to them from PubMed when they are available, just like he always does. But again, many thanks for the offer just the same.
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