My experience with this sort of stuff is that what seems like a happy surprise, is a mistake and it catches up to you.

Suddenly in November my providers stopped charging copays. Nothing for prescriptions. Nothing for office visits. Nothing for lab/x-ray. My monthly statement said I had reached my out of pocket maximum, but I knew I was about $2000 away from that. This month I am getting billed for the unpaid co-pays. They even tried to tack on a few bucks from 2013 (but I am disputing that).

No free lunch...

Jan

I thought it was a mistake too, but they told me no. It's all electronic Jan. They have my new insurance card scanned in their system since November 1. It's possible it was a mistake within their system that hasn't been picked up yet, but I questioned it and they know me there. They have my history at that pharmacy the past 5 years, it's a very professionally operated Rite Aid. They all know me on a first name basis- I am the Antibiotic Man, sort of like Spiderman but not a superhero. They don't even ask me my name when I come in for these prescriptions and I have gotten Xifaxin filled there every month for the past 5 years plus. It's never been $10 and it was always $40.

Maybe someone with a J Pouch hacked their copay network like the North Koreans hacked Sony? (causing Sony to cancel release of Seth Rogen's latest film - which I am not happy about). I wonder how it could have happened? If it was a hack of some kind how is that my problem? It's an accord and satisfaction if they charge me and I pay. They eat the mistake.

It's not necessarily an error. The lower copay just means it's on the insurer's preferred list. That could include lower-cost meds, like generics, but can also include branded drugs which the insurer has been persuaded to include, for various reasons. The insurer may have negotiated a big discount, or may have concluded that untreated hepatic encephalopathy (the labeled indication at the 550 mg strength) would be more expensive than the med.

And sometimes they just get the med on the wrong list.

Hope your right and it is good news. I have Kaiser and it is all digital record keeping on an integrated network and Kaiser pharmacies. Been going to the same pharmacy for 20 years. Mail order too. They all swear no copay was due. Then came the bill. The bean counters never let anything slip by.

The true test is what your benefits coverage states. I know that some drugs available only as brand name but treated as generic for copays. I think it is pretty rare though.

Jan

quote:

The lower copay just means it's on the insurer's preferred list.

That would mean their preferred list changed. We were on an Anthem/BCBS plan prior to November 1 and the copay was $40.00. Now on a different plan with Anthem/BCBS the copay is $10. And we are on a cheaper plan.

It's been the case for a long time that xifaxin was not available in a generic brand and it never stopped them from charging the maximum $40 copay before. You may be right, but why the sudden departure from past precedent with the exact same insurance carrier?

My insurance carrier changed pharmacy benefit manager (PBM) in January. I didn't change my insurance, but the preferred drug lists, mail order eligibility, and supposed generic equivalents all changed abruptly. Most disappointingly, the new PBM's database excluded VSL #3 DS.

Our office manager told me our copay tiers did change. One piece of bad news: my copay on the annual pouchoscopy has now gone from $500 to $1,000.00 (and the cost will be more than that so I can expect to pay $1,000.00). This is the case with any surgical procedure, we now all have $1,000.00 copays. So I may let the scope go for 2015 and do it in 2016 unless my GI doc really thinks it's necessary based on the results of my last scope in June 2014.

Holy crap, you used to pay $40? Wow, I have BCBS and the CVS pharmacy I have to use wants about $440 a month for it.

The copay was $40 on xifaxin. That is the maximum copay amount (or was) on our last Anthem BCBS plan. Now it's $10. Like I said, I feel like it's an early Christmas gift.

My copay for my pouch scope that I had yesterday is $20 because it is an office visit done in the GI clinic (would be considered a surgical procedure in the outpatient procedure center). My GI does not usually do the simple office sigmoidoscopies, but understands the patient cost issue. Since I do not use sedation, it is a waste. I also will have a $10 lab fee for the biopsies (once they bill me). I have active and pretty severe pouchitis right now, so I sort of wished I had sedation, but I was fine once I got rid of all the gas from the scope. But, after a day of Flagyl, feel pretty good gut-wise. Hopefully my change from Simponi to Cimzia will make a difference.

Sorry for hijacking your thread CT! Dealing with health insurance makes my head spin!!

Jan

My copays are starting to add up this year. I am over my covered labs (they cover 5 labs) this year so every lab test is $40 for me, whether it is blood work, stool test for c.diff, thyroid, etc are $40. I have a flex-sig under sedation in a couple of weeks and that is going to cost me $100.

At least my doctors visits are only $5.

My Xifaxin is $50 a month. Unfortunately it is not working any more for my pouchitis.

Actually you can't complain about a flex sig with sedation copay of $100. I have had a $500 copay on that the last few years and I am deemed to be someone who must be scoped annually due to my chronic pouchitis.

Jan your post is interesting and relevant to the topic of copays so there is no hijack. I hope that the flagyl clears out the pouchitis but given you are also on immunosuppresants I am concerned by your exposure to possible fungal and viral crap as you know I dealt with in the past when taking similar combos. Good luck with that. Keep your armpits and legpits dry after showering! Not much more you can do.

Still at $495 and still trying to fight it.
That's one nice holiday present!

What good is insurance if your premiums don't pay for coverage? On the other hand, better coverage means higher premiums. Pay one way or the other. In my zip code, premiums are very high.

Not sure how it works with other providers, but with Kaiser, you can get non-formulary drugs at the brand name copay if the doctor prescribes it as an exception (meaning the formulary choices have been tried and failed or his medical opinion is that this is the necessary choice). Doctors are given the final say (health plan approval is not needed). But, they can limit the amount. For example: I can only get a month's supply of my biologic injections at a time and have to pick it up at the pharmacy (no mail order).

CT, I have been lucky so far with no fungal problems, but I try to avoid antibiotics as much as I can. I've had rashes, but they've always been eczema.

Jan

My copay for Xifaxin is also $10 with BCBS. That might be for 2 weeks only...can't remember. Still, that would only be $20 for the month.

Xifaxin is $1381 for me with BCBS for a months worth, wish it would drop so I could add it my rotation.

Just thought I'd chime back in on this one as I just refilled a Xifaxan prescription. Still $10 copay through BCBS for me. If anyone is having a hard time getting it covered, it could depend on the dosing and the quantity. Mine was submitted as 550mg take one tablet twice a day for 30 days (#60) and with 3 refills. It was covered 100% that way.

Mine is covered exactly the same way under BCBS- $10 copay, 550 mg pills taken twice daily. However, it had been a $40 copay on the last plan we had with BCBS.

What is pouchitis like? Symptoms? I've had my j pouch since 1996. Haven't had to take meds or anything since surgery. But now my stomach is tender and sore.  I always have trouble with gurgling noises....loud gurgling noises now too.  Don't like going to the doctor for this...as I have felt the operation was a mistake and have regretted it ever since.  I want to take care of myself to be here for my family and I am a teacher as well. I find myself not eating during the day at all to avoid the gurgling noises during the day around other people and students.

I saw this on Bloomberg last week and remember this post.  The Chief Medical Officer of Express Scripts talks about Co-Pay Tiers, preferred drugs and effectiveness of drugs and a new tier of drugs called excluded drugs. 

 

http://www.bloomberg.com/news/...s-against-big-pharma

 

Could be that your insurer moved the tier for Xifaxan to their Preferred Tier of Branded Drugs.

I got approved thru Salix patient asst program. FREE! Love u Salix!

It's great that Salix has such a program.  I wish Cialis had one too!!! LOL!!!!!!

CT you can get a free trial!

Yeah I know, the free trial is 3 pills - a one time offer which I already used up. 

 

4 20 mg pills of Cialis, WITH my AAA discount on non-insurance covered meds, comes to around $154.  That is almost $40 a pill. It's greedy and cruel that the manufacturers of ED meds that mostly older men need to exercise a basic human function/need must charge such an insane premium.  Cialis is not this expensive in foreign countries which are charging more along the lines of $15 a pill.