United Health Care

HooRU

For the first time an insurance company rejected my appeal for Viberzi. I don't know what I'm going to do.

MacLeech

HooRU What was the rejection reason? Is the drug still listed in their formulary? Maybe there is a generic or alternative drug they will approve. Do they want you to mail order a longer supply? (My health insurance requires that for maintenance drugs)

We really need the rejection reason to offer decent advice though.

Otherwise, here is United Health Cares page on prescription drug appeals:
https://www.uhc.com/medicare/resources/prescription-drug-appeals.html

px_eliezer_

HooRU

Depends on what you're taking it for, but you should see if your gastroenterologist has some possible alternates.

broknsymetry

Looked it up in their formulary...

Rich221976

broknsymetry

It depends on your United Health Coverage.

Mine covers it.

Sparkchaser

Wow!! $1700 for a month's supply. Why are some of these meds so expensive?

takeahike

Sparkchaser Why are, [many if not most], ~~some~~ of these meds so expensive?

Relentless greed.

MacLeech

Sparkchaser Why are some of these meds so expensive?

New drug development is very expensive, as is the litigation if there is a problem found with it in longer term studies.

HooRU

It's crazy expensive. We're going to try loperimide another time. My bowles are a little better than they were.

Bobcat00

MacLeech

Why are drug prices lower in other countries?

MacLeech

Bobcat00 Probably a combination of less regulation, less litigious, and government subsidy. Along with the sheer fact of the United States in general has a higher demand for drugs. People will pay.

px_eliezer_

Bobcat00

As well, it's a big racket in the USA.

Many meds have truly obscene prices (even after development costs have been recouped) but then the drugmaker has "Patient Assistance Programs" also called PAP to help "lower" the cost.

They're pretty complicated (those programs) and require extra work from patients and doctors.

So---why not just have the price lower TO BEGIN WITH ??

Because the drug companies get certain tax benefits from having those "Patient Assistance Programs".

What a country.

NOT a fan of RFK Jr but if he can start to fix THIS it would be good.

Medicare, like other insurance plans, uses a formulary — a list of covered drugs — that is separated into tiers by copay amount. Drugs with lower copays are assigned to lower tiers, meaning they are preferred. When Medicare partially covers a drug’s cost, the manufacturer can use a PAP to lower the copay, and so get the drug assigned to a lower tier, without significantly lowering the actual cost of the drug. More patients may choose the drug over other options that cost Medicare less. For some critics of PAPs, this amounts to an illegal kickback — an issue raised in a least one report.
https://law.yale.edu/yls-today/news/experts-offer-clashing-views-patient-assistance-programs-kickbacks-and-court-0

px_eliezer_

Rising Drug Prices and Shortages Are Fueled in Part by the Very Reform Mechanism Intended to Curtail Them
https://www.acsh.org/news/2025/02/25/rising-drug-prices-and-shortages-are-fueled-part-very-reform-mechanism-intended

HooRU

There isn't a direct alternative. There is the drug that make Immodium, above that is Diclomine, and agove that is a medication that you take for 2 weeks to possibly cure it. I started with trying those over a decade ago. I've had IBS-D all my life, from a teenager until now. Viberzi changed my life. I won't get graphic, but I had so many traumatic events.

Rich221976

HooRU

Did the doctor's try and appeal it or did you send them a letter to appeal it?

Reason I am asking is that for my testosterone gel, they flat out denied it. I sent them a really nice and to the point letter appealing it and how the drug is able to help me. I was able to get it approved on appeal.

I have one more to appeal next, but I been waiting for my results first so that I can prove to the insurance that it is helping me. This one isn't on the list, but I am going to try and see if they will cover it since I already tried all of the meds on the list.

Rich221976

Expensive medication

Rich221976

They do list alternatives.

I noticed that a few are antidepressants.