Lialda - non formulary drugs - what does your insurance say it is

Okay, so what foes your insurance say it is???

If I wanted to go on Lialda, I couldn't because my insurance won't cover it. Not sure why though.

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Asacol offers the same outcome and most likely less expensive.  That is why it would be preferred.

My insurance says its a 50 dollar co-pay...

Post Edited By Moderator (dakotagirl) : 10/12/2007 12:44:04 PM (GMT-6)

Harpo - I just removed a word that I didn't think was appropriate for a family friendly site. I do agree however that a $50 copay is outrageous!

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Pan-colitis and GERD diagnosed May 2003

 

Asacol 12 per day,  Azathioprine 75mg, Rowasa and Canasa as needed

Aciphex, Effexor XR, BCP, Rhinocort nasal spray

Culturelle, Biotin, Folic Acid, Forvia, Calcium, and B12

 

Osteopenia (hip and spine) from prednisone use.  Started Azathioprine because I was steroid dependent.

 

Co-Mod for the UC forum

Keep HealingWell running smoothly:  www.healingwell.com/donate

Insurance formularies go out for bid. There are rebates etc behind the scenes from the drug co's to the insurance carriers etc based on what I have read.


Lialda is also new so they may not have had a chance to go head to head with Asacol in the process. I am sure they will going forward.

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My GI and i talked about remicade but my insurance said it was non-formulary and they wouldn't pay. But humira for some reason was covered. None of this makes sense to me. What I liked though was my GI went on a ten minute rant about insurnace companies and said that if the imuran didn't work he would figure it out for me.

I hate insurance at the same time i can't live without it.

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Kelly, 29

Left sided UC diagnosed 1/98 age 19, Pan colitis diagnosed 1/07
Currently on 4x3 Asacol, Rowasa every other night, 15 mg pred. until immuran kicks in...
75mg Imuran starting 8/23/07---bumped to 100mg 10/8/07
Prontonix once daily for acid reflux, zofran twice daily for nausea

I called and they said the drug was new - so I asked them to review it -
I then also emailed them asking them to review it -

my part was $70.00 - they paid $230 something -

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Diagonsed with UC in about 99 - 

Started new GI 9-25-07

Lialda 2.4 in AM(started 9-26-07) canasa 1000mg  2xs per day(started 9-26-07)
Probiotics, calcium with Vitamin D, slow release Iron, Psyllium Husk Fiber. 

kickbacks, shenanigans and cost containment

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Hint: any time your insurance denies something, question them. Ask to appeal the decision. Keep calling, they have hidden offices all over the country in many cases. I once spent a whole day talking to United Healthcare representatives - in Dallas, St. Louis, New York and finally California. Ask sincerely, whine, rant, cry, whatever. I made enough of a stir that each person kept kicking me up one level just to get rid of me, and I finally got to someone with the authority to override the decision and fix my problem. I work for the county, and they're "self-insured," so the insurance company just approves or disapproves the spending of my employer's money. My next step was going to be to go to the weekly county commissioner's meeting and speak to them publicly, in front of the TV cameras. I figured they wouldn't be happy to be portrayed as employers who deny their staff needed health care.

Your doctor will advocate for you. He will send a letter or two. He will not take a whole day to make these people uncomfortable, and he doesn't have direct access to decision-makers either. The sad truth is that your treatment was most likely denied by some high-school graduate with a computer program in front of him or her and no medical knowledge. The rules are made to keep their payouts low, so you have to advocate for yourself strongly. And be creative.

 

I was on a Lialda study for 7 weeks, with free Lialda,  but flunked out since I had not healed enough for their requirements.  I prayed my insurance would cover it so I made the call and believe it or not they covered it since they would consider Asacol a drug failure.  Apparently, they will cover it if you tried a drug on their formulary ( a list of drugs they prefer you use) first.

I feel so much better on the Lialda.  Mainly, the fatigue has disappeared and life is worth living again.  You forget what is normal after being sick for so long.  I used to feel as if labor pains had started again now its pretty normal, just the urgency.

I truly hope you can get yur insurance to pay.  Enlist your physicians help, mine just fax'd a form to the insurance the same day.  Its a nice drug for some of us.  Be persistant!  Also, I almost forgot, the makers of Lialda gave me a card limiting the $$$$ I'd have to pay out each month on the drug.  Not sure if this is only for the study participants, but it was a wonderfu  gesture.

 

I forgot, I pay $80. for a three month supply through Caremark and my insurance.  Not bad.

my insurance paid for Lialda, I think it was a higher co-pay, but I did the three month thing. now I just have the bottle sitting there..........knowing I can't take it = `(

don't know why I haven't thrown it out yet..........

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Beth, 32

Linda - you noticed less fatigue on Lialda? Very interesting! Might be something to look into :) Thanks.

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Pan-colitis and GERD diagnosed May 2003

 

Asacol 12 per day,  Azathioprine 75mg, Rowasa and Canasa as needed

Aciphex, Effexor XR, BCP, Rhinocort nasal spray

Culturelle, Biotin, Folic Acid, Forvia, Calcium, and B12

 

Osteopenia (hip and spine) from prednisone use.  Started Azathioprine because I was steroid dependent.

 

Co-Mod for the UC forum

Keep HealingWell running smoothly:  www.healingwell.com/donate

I also have a $50 copay for Lialda, but it works so much better than Asacol, and 2 pills once a day is easier than 4 pills 4 times a day!

I do have a card that I got from my GI from the company that makes Lialda, it works like a seconday insurance, and you pay no more than $25 for the pills. I guess it's their way of trying to make sure that even though their drug is not on the formulary yet, that we continue to take it and not switch back to Asacol. It's only good for 3 refills, but you can get a new card from the doctor after 3 times. :)

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Shannon

I just checked with my insurance. Lialda is a "preferred" drug - the same as Asacol. I have a maxium co-pay per prescription, so it probably wouldn't be any more than the Asacol - with this plan.

So, one Lialda pill is equivalent to three Asacol pills? I'd still be taking four per day - probably still split into two doses...

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Pan-colitis and GERD diagnosed May 2003

 

Asacol 12 per day,  Azathioprine 75mg, Rowasa and Canasa as needed

Aciphex, Effexor XR, BCP, Rhinocort nasal spray

Forvia and a Probiotic

 

Osteopenia (hip and spine) from prednisone use.  Started Azathioprine because I was steroid dependent.

 

Co-Mod for the UC forum

Keep HealingWell running smoothly:  www.healingwell.com/donate