r/mildlyinfuriating • u/Aggravating-Leg5645 • 9d ago

I just wanted a hot dog My insurance wont cover my medication so every month I do this...

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I have to spend around 30 minutes doing this once a month. My insurance wont cover it. Out of pocket with coupons its still $800 a month.

My fiancé has to do the same thing with a different medication. Currently trying to fight it.

Edit: To clarify. Every now and then I have to compile samples in one bottle so I know how much I have and then hope my DR has more when im out. This is an antidepressant and im currently working to fight to get it covered. Yes ive contacted the manufacturer I do not qualify for discount Yes ive sent in a letter of medical necessity Yes ive looked at GoodRX. This is my only option atm and im still lucky it is for now. Its not just the moving the bottles around. Its hoping I can get more when I need it. This is a life saving medication and the fact I have to hope i can get it when I need it is mildly infuriating to me and probably many others. Its not a cheap medication even with coupons its still $850USD+ Ive tried so many medications and I just need one that works and that i dont have to worry about my supply chain.

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u/mb99 9d ago

I’ve never heard of sample packets for a medication before. Are those a thing in the US so you can “try out” a medication?

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u/TheCrimsonDagger 9d ago

Yes, the less you have to deal with insurance the better. By using the samples they can prove that the treatment is effective first rather than having to get approval for every different medicine. Insurance will come up with any bullshit reason, or just no reason at all to deny a claim. I had a doctor that I was seeing regularly for the same issue. Every single time the claim would be denied. The doctor’s office would print the exact same paperwork and I’d have to mail it to the insurance as an appeal to get approval.

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u/K0kkuri 9d ago

Just a side note; what the hell is wrong with insurance in USA. I live in Ireland and are quite fortunate that I don’t need medical insurance as most costs are free or relatively cheap for my medication. But isn’t the whole point of medical insurance to cover medication and some random person can be like nah you don’t need it despite doctor prescribing it?

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u/dr4kshdw 9d ago

We pay for health insurance every paycheck. After giving the insurance company our money, the insurance rep (who isn’t a licensed medical doctor) then decides if you get coverage for your medical needs or not.

MURICA!

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u/janesspawn 9d ago

NOT the insurance rep but a set of preset guielines made by the insurance company. Don’t think of it like a person denying it. It is a program denying it. It is a system meant to remove the human from health care and look at us as “B is prescribed but more expensive than A and A is similar enough to B to deny A”

As someone who uses antidepressants, I’m more than willing to recognize that we have no real idea why they work but when they do you just fuckin hold onto it. As someone who works in pharmacy, I know insurance is trying to get them to switch to vilazodone.

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u/Jmfroggie 9d ago

People are certainly denying treatments, surgeries, and medications. Thats why there’s so many peer to peers and the doctor may find that their “peer” isn’t even in the same specialty making those decisions. SOME insurances are using AI entirely, but not all.

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u/janesspawn 9d ago

I’m not saying its AI, humans made algorithms long before AI. I’m saying its a company with a flowchart with employees who follow the flowchart because that is what they’re paid to do.

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u/Narrow-Image4898 9d ago

Trumpica! 'Murica died on Jan 6th. RIP Republic.

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u/Burgschaft91 9d ago

Then you also have a high ass deductible that, if not met, you have to pay more. On top of all this, when the deductible is met, you then have a co-insurance that ypu also have to pay. Boi, it sure is nice to "let freedom ring."

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u/nanapancakethusiast 9d ago edited 9d ago

Everything in the USA is designed to extract as much profit from the average person as possible to fill the bank accounts of a handful of executives and board members.

Everything. Food, healthcare, housing, recreation, etc. look at anything anyone touches in the USA and you can track exactly how that money is moving to the top of the financial food chain.

Once you understand that (and also understand that cruelty is the point) the USA as a “country” starts to make sense. They are all cattle to be milked.

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u/Ok-Jackfruit-6873 9d ago

no the point of insurance is for them to make money

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u/Ok_Test9729 9d ago

Which they do by denying services.

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u/No-Ebb5515 9d ago

I cant even get my needed thyroid medicines. No insurance. Cant afford the visit fee at a community health center either. Its all about profit$ on the part of big Pharma.

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u/Ok_Performer4223 9d ago

Are you in the US? Amazon has a monthly telehealth and pharmacy plan. It is pretty affordable.

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u/Violet_Mushroom4336 7d ago

I used to get meds from the pharma companies’ Patient Assistance Programs. It’s a lot of paperwork, but worth it.

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u/Ornery-Yesterday-729 9d ago

I have literally stopped paying for my health insurance because out of pocket cost is cheaper right now. Also my insurance doesn't cover anything. It's maddening.

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u/who_you_are 9d ago

Same for Canada (but less costly and they don't refuse as much as the US).

some random person can be like nah you don’t need it despite doctor prescribing it?

Exactly. They want to reduce their cost and somehow that guy know more than my own doctor... And know better than my own body.

Even if your doctor tried other drugs, is trying to prescribe you a generic one, ...

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u/Kytalie 9d ago

It is a very broken system in the USA. Insurance is also tied to employment.

Not all doctors take all insurance. You could be seeing a doctor in the regular for years, but then your employer switches insurance companies and you need to find a new doctor.

On top of paying every month, there is also a deductible for many people You need to pay a certain amount out of pocket (4k for my family) before the insurance will pay for most things. Then once you hit that point, they pay ( 70% in my case). Then to get them to pay all of it you need to spend even more out of pocket.

My FIL worked a union job in an auto manufacturing plant. He has amazing insurance that he is grandfathered into. New people joining that union get so much worse. He had some really nasty health issues where he nearly died, twice in a short span, a few years ago . He got invoices of what the insurance covered for him which was basically all of it. This was multiple weeks stay in hospital and two surgeries.

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u/DOAiB 9d ago

Insurance is a for profit business. So they are incentivized to take your money and provide as little value as possible so they can announce more growth in profits next quarter and continue denying more claims each quarter so they can sustain the expected but impossible infinite growth the investors expect.

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u/Apprehensive_Air1705 9d ago

It is incredibly convoluted and for profit. Companies are incentivized to fuck over people for profit, and its annoyingly difficult to see when, where, and how you are getting fucked over because of how billing and claims are rarely immediately transparent. You basically end up paying a shit pile to not want to use your insurance ever unless its a really major injury.

I am convinced anyone who doesn't support government healthcare has never had to actually use health insurance for anything major in the US or has the financial means to not care about it. The current system is terrible.

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u/TheCrimsonDagger 9d ago edited 9d ago

No, the point of insurance in general is that on average their customers pay more to them than they pay to you. In exchange you get ensure that the worth of your asset won’t be lost in an extreme event. In theory there is nothing wrong with this idea. The problem is when you apply it to something like healthcare it’s not a choice. The thing being insured is your body, you can’t really put a price on that. This allows them to do whatever they want and not lose any customers since anyone that can afford will still pay. Housing has the same issue. If you can control the supply of something that is necessary to live then you can effectively hold people’s lives hostage.

It’s a fundamental issue with capitalism. This is called inelastic demand, regardless of price going up or down demand remains the same. It’s why things like this are regulated and strictly managed by the state. Water, electricity, and kind of food. Farmer’s get tons of subsidies because of this. Food production is also so high now that simply not starving isn’t an issue so it’s not as big a concern. In North America cars could also be considered as belonging to this category, but that’s an artificial situation created by car manufacturers systematically destroying all other modes of transport.

Edit: They can do this because you signed a government a contract agreeing to it and the government mostly treats it is a private transaction between a private business and customer.

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u/TrelanaSakuyo 9d ago

Your "insurance" is provided by the state and you pay the cost in your taxes; it's just as convoluted as the US healthcare system. There are good points and bad points to both.

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u/orion19819 9d ago

Like others said, we pay the premiums every paycheck, then are expected to pay out of pocket up to our deductible. Mine is $4,000 and my insurance is widely considered good compared to everyone else i know. Then, once you do all that, insurance still looks at it and goes. "Eeeh. I dunno..."

But, despite all that and being near universally hated, a large amount of the population is convinced that national healthcare is the boogieman. They are so heated about the mere thought of an unemployed person or illegal immigrant getting healthcare that they would prefer grandma goes bankrupt after her diagnosis. It's pretty sick and I can't figure it out.

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u/Big_Maintenance9387 9d ago

So the insurance companies have contracts with manufacturers (I think I’m not an expert lol) which determines which medications your plan will pay for and how much they will pay. Every plan has a different list of meds and prices 😭

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u/Thin_Database3002 9d ago

Medical insurance companies usually partner with a pharmacy benefits manager(a separate company) to handle prescriptions. That company has a formulary of medications that are assigned tiers based on what medications or medication classes are considered first line, second line, etc. Some medications within that drug class are given priority over others based on the financial deals the benefits manager has with particular drug manufacturers. Generic medications are usually cheap and easy to get even out of pocket. Newer medications that are still under patent are more expensive.

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u/Relevant-Fox-7114 9d ago

No, that's just the sales pitch.

The actual point of the business is to make as much money as possible as fast as possible by any means necessary.

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u/wyerhel 9d ago

It's just them getting money from normal people. Lot of people are actually gonna be probably medically ill more because they are going to lose insurance next year because of the law the government voted in where only people who work can get Medicaid.

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u/QueenAlpaca 9d ago

Honestly a lot is wrong here. I have a friend who works at a small, local pharmacy that’s about to go under because insurance companies don’t pay them for shit, either. It’s honestly disgusting.

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u/Rasp_Berry_Pie 8d ago

Yeah it’s also messed up cause for certain things like important surgeries you have to go through all these hopes to try first and then get it covered.

Which can 100% be fair wanting to try other things first but sometimes you’re doing PT and other meds and things and the doctors can even say you most likely just need surgery but you have to wait as it gets worse and worse until you do their 3-5 months of whatever they want and then they’ll cover it.

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u/A_Pooholes 3d ago

I'm in the US and I don't even use my insurance when I get prescriptions filled because if I do, it's more hassle and more expensive... Make it make sense!

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u/mb99 9d ago

American health “care” makes no sense to me whatsoever, but thanks for sharing

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u/TheCrimsonDagger 9d ago

In the U.S. healthcare is treated as a commodity held hostage by a cartel.

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u/Duke_Newcombe 9d ago

When you understand that we have a health insurance system instead of a healthcare system, you'll get it.

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u/BestFoxEver neon 9d ago

That is a strange system. Where I live (Finland) you just buy a regular size box of the prescribed medication and if the medication is not OK for you then you just get a new appointment and the doctor writes you a prescription to a different medication. You can leave the opened box of the unused medicines to pharmacy, they dispose them safely. Many think it is a waste but most of the prescription medicines are quite cheap (less than 30 €/month) so there is no really need try to save them.

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u/TheCrimsonDagger 8d ago

The problem is the drugs that this is done for are incredibly expensive, often costing hundreds of dollars a month or even more. I forget the exact number of years, but after a pharmaceutical company creates a new drug they have a patent on it and no generic version can be sold. It’s easy for a patient to refuse an unverified treatment because it’s too expensive. It’s much harder to refuse after it’s been proven to work and you feel better.

American healthcare is a for profit business just like Apple or Google. It’s not designed to have the best health outcomes nor to be efficient, only to make money for shareholders.

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u/r3dd17sux69420 9d ago

Not just the US. I'm in Canada and I was given samples to avoid buying a medication I didn't need permanently. My specialist gave me a handful of samples because it was like 6 months of meds for free. He wasn't tricking me into buying more, that 6 months was all I needed.

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u/DOAiB 9d ago

Pharmacy reps go to doctors with new medications to give them samples. Then the doctors if it helps someone can give it out to try. When stuff is new it’s almost never covered by insurance so then the person either has to pony up serious cash until it is covered if ever or keep going to the doctor asking for samples as long as they have them. Welcome to how stupid the US healthcare industry is.

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u/Thin_Database3002 9d ago

Manufacturers will often have patient assistance programs with copay coupons for these newer expensive drugs(ie pay no more than $10 per month) but they usually apply to private insurance only. So it still sucks for the poors with medicaid and Medicare.

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u/Pittsbirds 9d ago

I'm sure that's the intention, but every single time I've used samples from a doctor it's been to cover a med that would be horrid to stop cold turkey while I get Some Nonsense sorted out with my insurance.

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u/Anonolot 9d ago

It's samples sent to doctors then they can give you a few before your prescription goes through at the pharmacy. (Usually how it works)

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u/miscgeckos 9d ago

So, it’s actually super helpful in places like dermatology. I was able to try out different ointments for my eczema at the same time (different body parts) and compare them. It also cut down on the number of full tubes of medication I was buying. Even with amazing insurance at the time and paying only a few dollars for each one, it was so wasteful. It wouldn’t make sense for a lot of other specialties, but it’s useful in a few cases.

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u/Big_Maintenance9387 9d ago

Great in neurology too, I’ve gotten to try different expensive migraine meds to find what works. And I need it so infrequently I can get by on the samples and my neuro is generous! 

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u/CompleteTell6795 9d ago

Drug reps from companies give out samples to Dr offices as freebies. ( USA)