Hello…I have been getting my prescriptions covered just fine by medicaid until my doctor recommended I start a new prescription. I agreed and didn’t think anything of it until I checked my insurance and it says I owe like $5,000 from this medication. I had no idea it wasn’t covered. Wtf do I do. I’m completely broke as it is. I can’t even come close to affording this. Am I gonna get sued?
Im 22f and I live in Texas I make like minimum wage basically I can’t afford a lawyer I’m using Medicaid.
Ask your insurance provider for your Prescription Formulary List—it shows all medications covered under your plan. Take that list to your doctor and ask if there’s a covered alternative.
If no alternative is covered, ask your doctor if they can talk to your insurance company and write a letter of medical necessity explaining why you need this medication and why the covered alternatives won’t work.
Also, make sure it’s not a medication that’s completely excluded from your plan. Some plans won’t cover certain drugs, like gender-affirming drugs, weight loss medications, or IVF hormones, even with a medical necessity letter.
With a $5,000 cost, it might be a specialty medication. Is it actually not covered, or is it a specialty medication that requires you to meet your deductible before coverage, and you haven’t hit it yet?
I kind of just want to stop taking this medication if it costs this much. I’m mostly worried about the amount the claim says I owe. No one told me it would cost thousands of dollars.
You don’t pay your insurance for medication; you pay the pharmacy. Pharmacies usually make you pay when you pick up your meds, unlike a doctor who sends a bill after treatment. The only money you pay to your insurance is your monthly premium.
Oh, thank you, I was really worried. Why does it say I owe thousands of dollars then? It says insurance covered $500, but I still owe about $5,000. My monthly bill says $0.
What says you owe $5000?
The health insurance website under claims it says $5000 is my responsibility
Can you post a screenshot or document of it? Personal info blacked out, ofc? Assuming you picked this up from a pharmacy already, whatever you paid the pharmacy should be all you owe— Pharmacies double check with insurance on what your portion is before they have you pay/pick up your meds. That’s why you typically have to wait a bit to fill a prescription, they’re filling the med AND checking how much they have to charge you per your insurance plan.
My guess is the pharmacy found a manufacturers coupon or copay assist and applied it for you. If not, they would have charged you the $1700 when you picked up the meds.
Be aware that copay assistance programs or coupons sometimes have an annual or lifetime limit, so future refills might not be covered as much. The pharmacy will let you know how much you owe when you pick up your medication.
You can ask the pharmacy if they applied a copay assistance program to your prescription to be sure. They should also be able to tell you the details of that program, like annual limits.
Oh ok but then wouldn’t it show that it was already paid then?
EOBs (Explanation of Benefits) don’t show how much you or a copay assistance program has already paid.
They just state that the pharmacy can collect $1,700 for this medication. If the pharmacy used a copay assistance program, they got money from the drug manufacturer, which means you owe less.
Ok thank you so much this was very helpful