Thread: Insurance

Most likely not because its not life threatening. They will cover blood work though. Unless your Dr can say its absolutely necessary for your health.

There lots of things they cover that aren't life threatening. Mental health, non-life threatening diseases, drug addiction, etc. Do you have Aetna or speak from experience?

Im on aetna hmo, my pharmacy plan doesnt cover it but if i submit it as a medical claim they pay for it 100%. They wont cover hcg or an ai.

Hey RippedG, Ive been in the health and benefits business for some time now. Ive worked at a PBM Pharmacy Benefits Management company and now I am working for a company that manages all benefits for Fortune 500 companies. One of my clients uses Aetna. It is not Aetna that defines your drug coverage. More than likely itis the company you work for itself that defines your drug coverage. They or Aetna depending on if the company you work for does fully insured or self insured will work directly with a PBM like Caremark. The PBM usually has a formulary that they use and the company will put limits or exceptions to this formulary.

When I worked at the PBM the client (your company) would make us have certain limits like only allowing 6 cialis per month or having a generic mandate or having step therapy. (You have to try viagra for X amount of time before you can go to Cialis for example). Many clients would not allow steroids of any kind to be covered. Many others would only allow them or other drugs with a Prior Authorization PA. The PA can be handled many different ways. The company may have someone at the actual company look at the drug and the Dr recommendations on a case by case basis or they can have the PBM look at it and if the DR recommendations and the patient/employee meet certain predetermained criteria, the PBM would grant the PA.

So as you can see, there are many factors that determine whether a drug is covered or not and you cannot just ask if Aetna, BCBS or UHC covers a certain drug. One plan under Aetna will cover a drug where the other plan does not depending on the client and/or the PBM. The company themselves can always call or email the PBM and say John Doe needs to be covered for this drug at this dose and the PBM can put in an override/PA into the system that allows the pharmacy to process the claim and allow you the copay they decide you have to pay.

Let me know if you have any other questions. I will be glad to help.

What about kaiser

Thanks Cav. Yeah, I had to go thru the prior authorization process to get my TRT approved and it was a pain and took a couple weeks. When I switched to injections from androgel, I had to do it again. The girl at the insurance company told me they are only allowing it b/c I am on the best plan available for my company and if I changed plans, I would not be approved. Now that we are switching, I had to disclose on my form that I am on TRT. We only have a choice of 2 or 3 plans but the only difference between the plans is the deductible where my other plan I had a PPO and could choose my dr. Not sure how the new one works. We change companies every year. What a pain. I like having a script and making it legal to have but I have enough test to cruise for 4 years if I need. There was a sale so I stocked up. I figure I could use it since I'll be on it for the rest of my life.

Yeah, it's a pain when a company is always changing health insurance companies. Usually, when they change, they will try to match up as much as possible coverage wise as what was offered before. Good to hear you stocked up! I need to. The pharmacy rapes people on prices. My test was $ over $100 for 1ml of 200mg Cyp. Ridiculous.

That is expensive. Come to find out that my insurance hasn't approved the injections. I paid $30 for two 1 ml vials and thought that was my copay. The pharmacist told me they are still waiting on approval and that price is with the discount card. Retail price is $25 each.

I spoke to the underwriter for our new insurance company so they know of it and I hope they will cover it. If not, it's not that much, only $30 a month without insurance. Had I known it was that cheap I wouldn't have disclosed it and just paid cash for it. I remember seeing a charge for like $200 on my insurance so I figured that's what it would cost me without insurance. But I think that was for a different script now.

Btw Cav, try Costco or SAMs if you have one near you. I've heard it's much cheaper. Those prices I told you were for Walgreens.