I'm sorry, but not surprised to hear that. Plans are changing the formularies all over.

My mom and I take different asthma medications. She's on Medicare and I have private health insurance through my employer. She can only take Advair and it's disallowed on her plan. I can only take Symbicort and it's disallowed on my plan. She is required to take Symbicort and I was required last year to take Advair. I told her we could each get what we were supposed to and switch it? Jokingly. And that it's both medications alllowed/disallowed, it's obviously not related to the medications.

This year, I am only allowed Breo or Dulera. But, Dulera causes horrible acid reflux and insomnia, and Breo TRIGGERED asthma attacks. I can get Symbicort now, but not at the typical copay, at $225 a pop. It's sick what they're doing right now. It has to change!

Oh, did you notice, two new, nowhere near patent expiration medications. That's my guess as to why I can't have Symbicort. Can you say collusion?

Do you have Caremark? Some BC/BS Anthem prescriptions plans do pay for this. Do you have a CVS pharmacy in your area?

Medicare covered our Prevnar vaccinations.

Rhizo -- If you are at all 'at risk' for pulmonary troubles, you might have a case to get your insurance to kick in for this. Our MD vaccinated both my DH and me in her office. She's not in not private practice; now part of a large hospital conglomerate. (If that makes a difference.)

Rob -- Who could blame you if you and your mom switched to get what you NEED! I just got a month's supply of Advair. I'm in the donut hole. I paid $156.34; my Part D Medicare insurance paid $215.34. Retail total...$371.99. That would be over $4K per year. As you know, there is no generic in sight for this stuff, which has been profiting Glaxo for at least a dozen years. This is no 'orphan drug'; it's a maintenance med for millions. The ingredients are not costly. Any research and development were recouped long, long ago. I'd love to know the profit Advair has generated.

It's not only Big Pharma, it's our *system*. I have to pay $400 a year to buy Part D insurance for the 'privilege' of getting my meds 'at a discount'.

At the risk of stating the obvious, remember that for those with private insurance plan coverage or partial coverage, what's in or out is what YOUR PLAN covers. It's not dependent on the insurance carrier. Yes, they all have standard plans, and some people are covered by those. Others with employer plans have provisions that have been customized for cost or other reasons for your specific employer groups.

One person with a BC/BS plan might have one drug covered, someone else also with BC/BS but under a different employer or plan may have very different coverage, co-pays, etc.

Ah snidely, more of what i know more about ( I was in insurance brokerage for 20 years). No one has control over what their pharmacy plan covers, correct? So what am I to do?

Not only can I not have ANY prescription filled that I want, I also cannot choose the price, and my employer is so restrictive I can only have it filled at their place of business. So am i to buy it out of pocket 100%? Do you have some other miraculous solution? Or perhaps I could just not use medications ?

True story - My elderly uncle had a heart valve replacement, had a brand new drug for blood thinner (Equilis or something similar) when discharged from hospital, I stopped at pharmacy to get this prescription for which he had been given a coupon at discharge for a free month. After that initial month, the cost was going to be several thousand dollars a month! As he could not afford it, the surgeon's office worked with the pharmacy at the hospital (uncle has BC/BS) to somehow obtain this medication for $10 a month!! The main difference with this drug was that it didn't need close monitoring/testing. There are so issues amiss with this situation that I hardly know where to start! Luckily, the afib ceased after the first six weeks and he doesn't need a blood thinner now.

Prescription costs are insane!! Drug companies say that the costs are so high because it costs billions to bring one drug to market. I don't know what the solution is but there has to be one. Did you hear about that young CEO of Touring that was running a ponzi scheme, the one that had raised the price a pill from 13.00 to 700.00? At least that's one dirty pharmaceutical executive getting his just due, if he doesn't wiggle out of it with expensive lawyers.

The asthma med that I am on for the past 20 years is flovent. While still expensive (my copay is 50.00) it is no where near as expensive as those others, with a lot less side effects. It is a steroid inhaler, and I have had zip size effects from it and it controls my asthma so well that I can run a 5K and do HIIT exercise with it.

sleeperblues -- Odd that MD's had me try Singulair and Symbicort, but never Flovent. I've been on Advair since it first came out -- around 2000, I think. Looks like Flovent is Advair without the salmeterol (bronchial dialator). Both made by Glaxo?

Retail for Advair is $370/mo. I'll have to look up Flovent.

Added: I find Flovent at $210/mo. I also see that that one can buy fluticasone as a generic, but not in a powder for astmatics to inhale. Anyone have further info on flutacasone?

rob, I'm not sure if you're asking me a question or just expressing frustration. It sounds like you work for a medical group or medical center (medical school)? For such employers, restricting certain services or prescriptions to in-house sources is a common cost control technique. Not unlike students at such medical centers who have student health insurance (rather than through parents, spouse or other sources) - their first stop for care is the Student Health Service or its equivalent within the institution and then specialist referrals are similarly to departments within the school.

I'm not expressing frustration with insurance, although it needs an overhaul. The last post is about your limited view on how prescription programs reimburse. You came across as someone who acts ike we have somehow earned the the reimbursement program we have, or are too dumb to know how to get out of it! Your condescension is confusing, and fully unwarranted

As I misunderstood your comment, you've largely misunderstood mine. We can leave it at that.

I take no meds, and neither does my husband. Our doctor is amazed that we don't "require" any prescriptions to keep us healthy.

We eat organic, non-GMO, non-processed foods. We exercise. We are not overweight. Both of us have normal blood pressure, blood work numbers, etc.

Healthy living is a lot less expensive than treating illnesses (sometimes) caused by improper diet, obesity, and crap-for-food.

36% of Americans are obese. Do the math!

What the hell does that have to do with pneumonia?

If the incidence of pneumonia is unaffected by a person's weight, then nearly two-thirds of people who contract pneumonia aren't obese. That's what.

Yalehouse, sorry to hear of your diagnosis. I was dx'ed with breast cancer over ten years ago and had no chemo, no radiation, no hormonal replacement. Until that moment, I hadn't taken my diet and lifestyle into account, although I had quit smoking three years prior to that.

I sincerely hope that your statement that I'm "lucky" and "so far" isn't a wish from you for misfortune to befall me. :) Have a wonderful day.