should I fight the insurance company?

here is the scoop. I have asthma and few years ago my doc was looking for an inhaler to give me that would help me out, so I gave him a list of meds that my insurance company would cover and he said ok I want you on symbicort inhaler. but he gave it to me in samples first to see if it would work and after say 2 months on samples I said it worked and he sent it to the pharmacy for me. I get there and they said insurance will not pay for it anymore so in those 2 months they stopped covering and I did not know that as I was on samples of it first. they said I had to try breo and dulera inhaler with fail in order to get symbicort, I was on dulera then and it was not working so got put on breo and it was ok at first now it not working well and my asthma is uncontrolled and I am constantly sick, so my new asthma doc said he would put me on symbicort again to see if I get better as I said that works best for me. insurance would not pay for it the nurse tried to get it covered they said no the doc tried to get it covered they said no again and to try such and such an inhaler. they sent me a letter saying now that I tried breo and I also have to try air duo now before I can get the inhaler I need. can I fight this as they told me first I needed to try 2 inhalers with fail and I did and now they are telling me I need to try a 3rd one before I can get it? when I file a complaint what do I say to them about this? I am so pissed off that they are denying me meds I need to help me?

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  • lucy
    Lv 7
    2 years ago
    Favorite Answer

    https://www.goodrx.com/asthma/drugs

    My first thought was that Symbicort was way more expensive vs the other 2 drugs.

    But found that Symbicort costs $342 and dulera costs $326, but could not find the cost for breo. So based on these costs is not a big difference.

    Now the costs I found is what (you) pay if no insurance, since (if) insurance covers it, then they would have a “negotiated” rate with the pharmaceutical company, that say for instance last year your insurance would pay $275 for Symbicort, but this year would have to pay $325, thus they dropped it off the formulary.

    The same thing applies to doctors and specialist that may cover 1 year and the next don’t since insurance can’t agree on how much insurance will pay.

    So your only chance is to appeal this and you should get a letter from your doctor that this drug is the only one that can treat your asthma. But be advised that when you file an appeal, then it could take at least 30 days or more for a decision.

  • 2 years ago

    You have to work through the cheaper options before they give you the pricey one. Symbicort is a fancy name brand and there are likely other drugs which would work for you...

    You just have to prove that you tried those other drugs but they didn't work before the company authorizes the more expensive option. Its basic economics, just frustrating in your position...

  • 2 years ago

    Your insurer apparently has a better cost deal with a supplier(s) other than Symbicort. What you are experiencing is not unusual at all. Insurers want you to try the least ex

  • Judy
    Lv 7
    2 years ago

    Your doctor, not you, should appeal the decision.

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  • 2 years ago

    A few years ago symbicort and dulera worked. Now dulera stopped working -- how do you even know that symbicort still will work? unless you have gotten recent samples, which it doesn't sound like you have, you don't.

    So what's the big deal - try air duo.

    Why do you need to try Air Duo first? Because it is a generic version instead of name-branded pharmaceutical.

    Why do you have to try this first? Probably because the insurance you have ALWAYS requires you to try the generic first before a name-brand. This is often the case. It was only released in 2017 so wasn't even an option "a few years ago".

  • J M
    Lv 7
    2 years ago

    Welcome to the American healthcare system. This is sadly very common. Insurance companies try to get you to go on cheaper drugs because it costs them less.

    • Anonymous
      Lv 7
      2 years agoReport

      What about the pharmaceutical companies overcharging?

  • 2 years ago

    You don't file a complaint, you file an appeal. Call the insurance company's customer service line and ask how to file an appeal - you will most likely be required to get your doctor to help file the appeal by submitting a letter explaining that you have not responded to the first two medications and that using the Symbicort samples proved effective.

    There is no guarantee this will work, but it really is your only chance - insurance companies are allowed to establish their own formularies (lists of medications they will cover and under what circumstances they will cover these meds) and there are no requirements as to what goes on or doesn't go on these formularies. Note that the formularies tend to change annually, and it is up to you to check with your insurance company each year to see if what you are taking is still on the list or has been added to the list (you can usually get a list of the new formulary by contacting your insurance company each year).

  • tro
    Lv 7
    2 years ago

    the insurance company has some reason they won't cover the one you need but will others,

    you probably need to find out why they won't cover the one that will help you or simply pay for it yourself

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