https://boards.hellobee.com/ Pregnancy, Baby and Parenting blog, by Hellobee en Tue, 26 May 2026 08:41:06 +0000 https://boards.hellobee.com/topic/us-health-insurance-please-explain-to-me-like-im-five#post-1414338 Tue, 11 Feb 2014 12:37:20 +0000 LindsayInNY 1414338@https://boards.hellobee.com/ <p>This generally only occurs with medications that are not taken on a daily basis - think migraine medicine, Viagra-type drugs, some sleep aids (Ambien). This is meant to prevent abuse and long term use since they're typically not taken on a daily basis. Like others said, I'd give your insurance company a call to figure out how to get them to cover more per month. </p> https://boards.hellobee.com/topic/us-health-insurance-please-explain-to-me-like-im-five#post-1414305 Tue, 11 Feb 2014 12:29:05 +0000 T.H.O.U. 1414305@https://boards.hellobee.com/ <p>Ive heard another friend that went through this with her pregnancy. </p> <p>You could also see if your doctor would prescribe something different and maybe you could get 12 zoloft and then 12 of something else? I'm sure there are ways around this, they just make it hard. </p> https://boards.hellobee.com/topic/us-health-insurance-please-explain-to-me-like-im-five#post-1414226 Tue, 11 Feb 2014 12:02:34 +0000 spaniellove 1414226@https://boards.hellobee.com/ <p>Wait...they would only cover 12 generic pills a month? </p> https://boards.hellobee.com/topic/us-health-insurance-please-explain-to-me-like-im-five#post-1414214 Tue, 11 Feb 2014 11:59:28 +0000 jedeve 1414214@https://boards.hellobee.com/ <p>Your pharmacist probably just meant he can only give you 12 covered by your plan, assuming you wouldn't want to pay for the rest.</p> <p>Doctors run into problems like this all the time and will probably be able to adjust your prescription accordingly.</p> <p>Welcome to the hell of American insurance. Our apologies. </p> https://boards.hellobee.com/topic/us-health-insurance-please-explain-to-me-like-im-five#post-1414201 Tue, 11 Feb 2014 11:55:53 +0000 yoursilverlining 1414201@https://boards.hellobee.com/ <p>I agree with what everyone else has said and had one additional thought: Zoloft (or its generic version whose name I can't remember) is a drug that has been on the market for a very long time– so I would ask your pharmacist how much it would cost to pay out of pocket. It isn’t fair (and it seems counter-intuitive) but I’ve run into situations where it’s cheaper to pay out of pocket for drugs than to pay the co-pay amount. </p> <p>I took Zofran throughout my pregnancy, multiple times a day and my insurance company never had any issue whatsoever with me filling multiple Zofran Rx in a month (I took 60 pills + a month on average, sometimes 4-5 pills a day) </p> https://boards.hellobee.com/topic/us-health-insurance-please-explain-to-me-like-im-five#post-1414193 Tue, 11 Feb 2014 11:53:27 +0000 looch 1414193@https://boards.hellobee.com/ <p>@farawayviolet: I'd call the doctor's office and ask if they can do the generic. I know the way my prescription plan is worded, that they will only cover the brand name if there is no generic readily available. </p> https://boards.hellobee.com/topic/us-health-insurance-please-explain-to-me-like-im-five#post-1414185 Tue, 11 Feb 2014 11:51:18 +0000 farawayyama 1414185@https://boards.hellobee.com/ <p>@BakerBee: Thank you, it is really helpful, and easily understood haha!<br /> @blackbird: Yeah, a 30 day prescription - for the generic. I am allowed 2.6 more 30 day 12 pill allotments before Feb 2015.</p> <p>Thank you everyone, I will talk to my doctor and look at making an appeal. </p> https://boards.hellobee.com/topic/us-health-insurance-please-explain-to-me-like-im-five#post-1414174 Tue, 11 Feb 2014 11:47:36 +0000 farawayyama 1414174@https://boards.hellobee.com/ <p>@looch: yes I do. From what I gather (again, I'm foreign and still learning) we have good but not amazing insurance, with a dental and a prescription plan. </p> https://boards.hellobee.com/topic/us-health-insurance-please-explain-to-me-like-im-five#post-1414173 Tue, 11 Feb 2014 11:47:31 +0000 Chillybear 1414173@https://boards.hellobee.com/ <p>i would call your insurance first (member number on the card) they might tell you your plan prefers a certain generic or it might be easier to get the script through the mail order pharmacy. then i would call your dr and see what they recommend.... 12 seems like an odd number since i would think 30 would be once a day </p> https://boards.hellobee.com/topic/us-health-insurance-please-explain-to-me-like-im-five#post-1414169 Tue, 11 Feb 2014 11:46:53 +0000 blackbird 1414169@https://boards.hellobee.com/ <p>Did your dr write the script for X days? I know when I get birth control, I take it at a rate faster than the average woman (back to back, instead of actually having a period) so my Dr has to write the script specifically for that </p> <p>If it's a long-term use type medication, a lot of insurance companies only do mail order for them. Mine used to be Aetna for prescription and anything that I took "regularly" had to be ordered through a website and shipped to me. </p> https://boards.hellobee.com/topic/us-health-insurance-please-explain-to-me-like-im-five#post-1414161 Tue, 11 Feb 2014 11:45:30 +0000 LBee 1414161@https://boards.hellobee.com/ <p>@farawayviolet: I had this same problem! </p> <p>In a nut shell, they aren't overriding your doctor, per se, the pharmacy will still give it to you - you just have to pay like $150. They are just saying they won't pay for more than 12 pills because obviously some dude is up there proclaiming morning sickness only occurs sporadically or something ridiculous like that. Zofran is not considered by insurance companies as "round-the-clock needed" (don't get me started on this) unless you are diagnosed with hyperemisis gravidarum. What you will have to do is call the insurance company and request the form that allows you to get medicine over the quantity limits. Your doctor then fills it out and requests that you are able to fill 60 pills every 30 days (assuming you have the extended release kind - i.e. the kind that dissolves on your tongue). I had already been told I had HG so this part wasn't an issue for me, but my specific insurance company (BCBS) doesn't approve it unless you are diagnosed with HG. In other words, you will want to mention to your doctor that your insurance companies requires them to provide a diagnosis or they will just reject the approval request. The approval process is usually fast tracked and you should get a letter from your insurance company pretty quickly that you can take to your pharmacy. </p> <p>In the mean time, I would recommend taking Zofran as late as you can make it in the morning (assuming you have the 12 hour pill) and and going to be early. That's what I did until I got my approval. I know it stinks, though. </p> <p>I hope this helps. I'm sorry if it isn't completely five year old level! </p> https://boards.hellobee.com/topic/us-health-insurance-please-explain-to-me-like-im-five#post-1414159 Tue, 11 Feb 2014 11:44:09 +0000 looch 1414159@https://boards.hellobee.com/ <p>Do you have prescription coverage, separate from your health insurance policy? </p> https://boards.hellobee.com/topic/us-health-insurance-please-explain-to-me-like-im-five#post-1414151 Tue, 11 Feb 2014 11:42:27 +0000 littlebug 1414151@https://boards.hellobee.com/ <p>I don't know that anyone can explain how it works or why the insurance companies can over-ride the physicians. It is one of the biggest - if not the biggest - problem with healthcare in this country. Some medications require prior authorization, so I would have your physician call to see if that is the case. And if it's not, then I would have your physician do an appeal. </p> https://boards.hellobee.com/topic/us-health-insurance-please-explain-to-me-like-im-five#post-1414139 Tue, 11 Feb 2014 11:38:57 +0000 farawayyama 1414139@https://boards.hellobee.com/ <p>So, I'm fairly new to the US and am 8 1/2 weeks pregnant. I have morning sickness and my OBGYN prescribed me a month's supply of Zofran. I get to the pharmacy to pick it up, and the pharmacist very apologetically said that my insurance company (aetna) would only give me 12 in a month. How does this work - Why was the insurance company able to override my doctor? Is there anything I am able to do about it?</p> <p>I've never had this problem before, either in the other countried I've lived, or with my Zoloft here in the US, which I'm off at the moment, but usually take daily. </p>