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NYCE PPO Prime Therapeutics Hiv meds

hello all,

writing my issue is my last resort. After NYCE PPO switched the pharmacy from Express Scripts to Prime Therapeutics, I am no longer able to fill my rx for hiv med: Biktarvy. I have the Rx Rider. On Prime Therapeutics website the medication shows up as covered 90day supply for 50 dollar copay, but when I go to a pharmacy that is in their network for a 90day supply (my doctor sent a 90day supply) the insurance denies a 90day supply, (but on emblem health nyce ppo website it says i can get my 90day refill for tier2 meds) But the pharmacies (including specialty pharmacies) keep saying they can only fill 30day supply and it is with a copay $1800 per month. An impossible amount. Their call center people all say different things, I am being kicked in between the insurance pharmacy and the doctor and endless verification processes.

Is there anyone who can help me? I am losing sleep, I can’t even eat thinking the worst… Thank you in advance.

  1. Hi . Your frustration and anxiety is certainly understandable. So many here have experienced these insurance fights. I have to tell you that we are not medical or legal professionals and, for your protection cannot provide advice on those fronts. That said, every state has a healthcare ombudsman's office (the names vary) to help with such issues and here is a site for NY: https://ag.ny.gov/resources/individuals/health-care-insurance/health-care-helpline. In addition, I want to share with you this article from our editorial team on managing healthcare costs, which, among other things, mentions contacting the manufacturers directly: https://h-i-v.net/resources-cost. It is in their interest to make sure people can get their drugs and some people have found it helpful to work with them. It is also important to document things and have screenshots of what the website is saying that doesn't match what happens at the pharmacy. I know this doesn't solve the problem, but I hope the information is helpful and that you can get the care you need soon. Best, Richard (Team Member)

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