HELP! Need urgent help with medication!

Matthew74

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Does Medicare part D really not cover some brand name medications at all?

I lost my insurance. I was declared disabled sometime back, but have never used Medicare before so I didn't know the first thing about it. I thought I could depend on it when my insurance ran out. I'm looking at Part D plans. It *appears* as if brand name Tegretol and Felbatol are not covered at all. I've never been in this situation before - there was always some way to get them.

I lived for many years without insurance and always managed, but this is the worst.
 

Matthew74

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I called 4 part D providers. It looks like brand name Tegretol XR and Felbatol are not covered at all under part D (at least in my area). It's not a matter of prior authorization, etc. Some brand names simply aren't covered at all. Apparently the only way you can get them is if you file an appeal with a letter from your doctor, which may be denied. These are the best plans available in my area.

Even the generics are insanely expensive, depending on the provider. I'm talking about $100-500 for carbamazapine extended release or $200-1500 for felbamate, each month. Generic. This is because the generics are usually tier 4 drugs, which means that you can't pay a co-pay, but have to pay a percentage of the total cost. Under some plans your out of pocket actually goes UP after the first months. The only way to get around that is to request a tier exception, which has to be approved. This could make your meds a tier 3 rather than 4, which means you would have to pay less percentage, or only a co-pay. Remember these are costs for the generics.

The out of pocket max is many thousands of dollars, so that even at those prices, you many not hit the out of pocket limit in a year.

The insurer has to "request" that the plan goes into effect on the first of the month with the government. It may or may not go through the next month - you may have to wait a month.

I found only one insurer that said that the generics were covered under a co-pay. YOU MUST SHOP AROUND AND CALL EACH PROVIDER - ASK WHAT YOU WILL PAY FOR YOUR MEDS. Your cost can change a lot.

I have enough Tegretol to get me through until I can file an appeal. I know for sure I've had problems with generic Tegretol. I have no choice whatsoever but to take generic felbamate for at least a month. As Cint mentioned in my other post, as far as we know, there are about 5 manufacturers of generic felbamate - which means my level could change every month. This is my best option right now. I believe this is wrong.

My advice: Get something besides part D, if you have that option.

4/29/2020
 

Porkette

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Hi Matt,

I'm sorry that Medicare won't cover for the tegretol, seizure med can be very expensive. You may want to look into GAP insurance
you can get it at the office of the aging in your area. They can set you up with insurance that will pick up what Medicare won't pay.
My mom got the gap ins. and she only pays $45.00 a month and it covers everything medicare doesn't. I wish you the best of luck
and May God Bless You!

Sue
 

Sabbo

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I agree that AEDs are INSANELY priced. A few years ago I was taking 400mg/day of both Vimpat & Topamax. I had to switch from Vimpat to Zonisamide because my husband's new insurance wouldn't cover any of it. To stay on it, I would have had to pay $1600/month just for it. Even then, the copay was $300 for a 3 month supply of generic versions of everything.
 

BIGMAN131307

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Apparently the only way you can get them is if you file an appeal with a letter from your doctor, which may be denied.
You need to get your doctor be a big fighter for you. If the only AEDs that will help you are name brands, then the doctor has to have that spelled out loud and clear to them. It may take some doing, but it can be done. I had to go toe to toe with my previous doctor about this same issue. After going through the 15% variation speal, I noted my issues with all the generics. The rotating generics weren't helping me, just hurting me. So my then doctor got my insurance to approve my name brand Trileptal. Which currently goes around $2000+/month. Which I'm still taking even after my surgery, and plan to stay on for some time.
 
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I lived for many years without insurance and always managed, but this is the worst.
My daughter is on Vimpat and it has been working really well for her. My husband recently switched jobs and we went through the same problem. Our copay jumped from $70 to $300 per month. I talked to the pharmacist and found out that you can get coupons for these brand named drugs. He signed me up at CVS and Vimpat sent me an email with a savings card and it brought my copay down to $20 (!!) I was about to pay the $300. I am so thankful he told me about it. Also they just sent me another email with a new card, so I think you can just keep getting coupons each month. Talk to your pharmacist about it or call CVS.
Hope it works for your particular drug..Good luck!!
 

Sabbo

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That insurance company required the use of their mail order pharmacy for medications needed for chronic illnesses. Walgreens & CVS could only be used for short term prescriptions. I do prefer a mail order set up, but I think Walgreens is the best. Most of the insurance companies we've had have used them.
The deal that the employer with the insurance company must make a difference, too. My husband has a different employer, & we have an insurance insurance company that we did before. Recently, I called for a 3 month refill of my AEDs, and was shocked when I went to get them. I expected to pay around $300, as I always had--when this was our insurance company before. Now, my copay is $48 for a 3 month supply!
 

BIGMAN131307

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I expected to pay around $300, as I always had--when this was our insurance company before. Now, my copay is $48 for a 3 month supply!
That may have been because of coronavirus. Many providers are allowing 3 month supplies.
 
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