Drug no longer covered?

[amanning]

What is the name of your state?Texas

My kids have been on group insurance with the same employer since they were born. The employer has "self-funded" insurance and changed "third party billing administrators" from Boon-Chapman to Blue Cross.

I tried to get a drug filled at the Pharmacy that my son has had to take for years called Lupron. Without insurance the cost is around $1200 per dose.
The Pharmacy could not fill it for me because when they tried to process it through the insurance, they were told that they "no longer cover the drug".
Can they do this? There is no substitute for this drug.

 

[rmet4nzkx]

How old is your child, how long has he been taking Lupron, what is his diagnosis? Does he have any congential birth anomolies or genetic disorders?

 

[amanning]

He is 5 years old, has been taking Lupron for at least 1 1/2 years if not 2.
He is diagnosed with Precocious Puberty which is a genetic disorder.
He was diagnosed at birth and has never had a lapse in insurance coverage.

 

[alias420]

Have you thought of using an online pharmacy?

Have you considered trying to use a Canadian pharmacy for this drug? Perhaps it isn't as expensive up there.

 

[Caelda]

Is it a non-covered drug or does it require a pre-authorization? Contact your insurance company to confirm.

 

[porcelina68]

generic is formulary

What is the name of your state?Texas

My kids have been on group insurance with the same employer since they were born. The employer has "self-funded" insurance and changed "third party billing administrators" from Boon-Chapman to Blue Cross.

I tried to get a drug filled at the Pharmacy that my son has had to take for years called Lupron. Without insurance the cost is around $1200 per dose.
The Pharmacy could not fill it for me because when they tried to process it through the insurance, they were told that they "no longer cover the drug".
Can they do this? There is no substitute for this drug.

The generic form of this drug, leuprolide, is formulary. Get his doctor to check the "ok to substitute generic" box on the prescription form, and you should be good to go. You may have to call different network pharmacies, because not all of them carry every generic drug.

 

[ablessin]

when the employer changed to a self-funded status, they probably took a look at the covered benefits they offered the employees.
They most likely took the list of very high cost items and made modifications to the coverage type of them (meaning not covering anymore).
They usually do a study to see how many employees the change would affect before making huge and drastic changes. If there is only a few employees that would be affected, they will make the change, and let those few people figure out another way to get the visit/drug paid for.
Is your spouse employed? perhaps they could pick up coverage and (but check first) the Lupron would be covered. Or, if you can't get the generic, you might be able to get drug supplement, (eg, Medicaid).

More and more employers are moving to self-insured, to help ease the cost of premiums, and to control covered benefits.... families are going to start to see a hike in what they pay out of pocket.

Good luck