Paxlovid not covered by my insurance: a workaround

[JustABozoOnThisBus]

After getting all the shots and the boosters, Covid bit me, very uncomfortable. My doctor called in a Paxlovid script for me. The drug store (CVS) told me the insurance denied my coverage. That'll be $1600 please.

Then someone else from the drug store got on the line and talked about a Pfizer program that could be of some help.

Googled "Pfizer patient assistance". The first thing in the list was titled Pfizer RxPathways, For Patients. It led me to a form, easy to fill out. Ten minutes later, it displayed something that looked like an insurance card. I called the pharmacy back, gave them that info, they said it was accepted and my co-pay would be zero.

I don't know what games are being played, or why I qualified (maybe because I'm on Medicare), but I got the pills and saved $1600. I felt so bad that I was thinking about just paying, to get the meds.

Supposedly, Phizer started a new policy this year.

[DURHAM D]

1. It is covered by Medicare through 2024 as

I understand it.

[lapfog_1]

2. Mine was $1200 at Safeway

there was mention of a program to get the co-pay to zero but I, isolating since testing positive and was sooo sick by day 3... sent my friend to get the drugs... he had my ID and my debit card for my HSA. So I just told my friend to get the damn drugs and I would try to get my insurance to cover it later... after all, this saved them 10s of thousands had I gone to the ER and ICU.

5 days later and I was getting much better. a week after that I still have a cough, but it is not that bad now... slowly getting better.

Fully vaccinated and boosted. Wouldn't wish this Covid on anyone.

[JustABozoOnThisBus]

14. Did you go back to Safeway to see if they can recalculate the cost?

Maybe after getting info from the Pfizer Patient Assistance program? Maybe they can shift some of that $1200 to "elsewhere".

Fully vaccinated and boosted? Yeah, me too. I guess this could have been worse: I didn't go the ER and get intubated or whatever was done in the days before bleach and ultraviolet light injection.

[AZSkiffyGeek]

3. Manufacturers coupons in general are great for name-brand drugs

At least they have been for my wife and I - we’ve been able to get coupons for every expensive med that has reduced costs down to around $25.
My understanding is that is different once you are one Medicare, however.

[Trueblue Texan]

4. This is true...

I recently had a prescription that was $165, even with my Medicare Part D. I asked the pharmacist if there was a discount with Good Rx or some other entity. She said, "Sure! Let me get you a coupon!" It was $20 with the coupon. This is the same amount my doc showed me it should be on her phone. There are definitely some games being played, but I think they're with the pharmaceutical companies more than the docs or pharmacies.

[CurtEastPoint]

5. Insurance companies, Rx companies, it's all a shell game to the tune of GREEDY PROFITS. GD them all. SINGLE PAYER

[Liberty Belle]

6. I got it free proactively when traveling to AFrica, where it's not widely available in hospitals.

Interestingly my doctor prescribed it for me to bring along just in case we got COVID in AFrica, but my husband's doctor refused to do so. We are both seniors over 65. There was no charge.

If you are traveling abroad to a third world country, it may be worth trying to get Paxlovid ahead of time and then stash it away when you return in case you need it later and insurance coverage goes away.

This should be free for everyone!

[Warpy]

7. One thing I have to say Wally's is really good about

is checking for Medicare coupons and other deals, usually without being asked.

Plus, I can stop on my way out for a bagful of the weird veggies that nobody wants to deliver, probably because the kids doing Instacart don't cook and don't know one veg from another.

[LiberalFighter]

8. I think Medicare should have covered it.

If you have an MA plan then the fault lies with them.

[erronis]

9. I'm guessing pharma is just gaming the Medicare payments.

When we go to the pharmacy with a Medicare card and get charged just a few dollars, the pharmacy (big business) charges Medicare for the full amount. PROFIT.

If a savvy consumer comes in with a coupon and gets a discount, this isn't reflected back to Medicare and the pharmacy still gets the full amount. PROFIT

CMS - Dept. of Health and Human Services / Center for Medicaid - Medicare is woefully understaffed and even more outgunned by the big guns of Pharma and the insurance companies. They can't possibly police every new tactic that these money-grubbing and patient-harming companies are doing to the population.

[surfered]

10. Medicare should have paid for it...

…unless you have Medicare Advantage (maybe?)

Also, to be effective, it must be taken within 5 days of symptoms.

Good luck.

[JustABozoOnThisBus]

15. I don't have "Advantage", just the old parts A, B, D.

The pharmacy has my Medicare info, from when I got Covid vaccines.It's all confusing, but I've been taking the Paxlovid for a day and a half and I feel much better.

[LetMyPeopleVote]

11. I am very glad that you got your script filled

[quakerboy]

12. Not covered?

Im not on any special program, but in october i was told by multiple pharmacies that the feds were still covering paxlovid for all, as long as a dr provided a proscription for it, regardless of insurance.

[Josiesdad]

13. Yeah... it is all part of a self dealing game...

From an article published in Time Magazine back in 2019. The gist of it is that the game is to a large extent rigged by the Pharmacy Benefit Manager system (aka PBM)

Manufacturers, competing to secure high formulary tiers, know PBMs want juicy rebates. And so they have two options: offer a larger discount and make less money on the drug, or offer a larger discount while also raising the list price of the drug, therefore keeping the net price level. If you’re a manufacturer, you’re going to pick the latter option.

The compensation that goes to PBMs is not driven by providing value to the patient. The manufacturers' list price is pure fiction unless you are a patient unlucky enough to not have the drug in question be be included in their insurance company's formulary. The coupon system is the manufacturer's means to preserve market share in spite of the price fixing efforts of the PBMs.

Too bad the class action system in this country doesn't work any more.