My Aetna Medical Insurance Doesn't Cover Compounded Medications

[+ Gar1eth]

So it won't cover Trimix. I was wondering if compounded medications were a common exclusion.

 

Gman

[Max]

So it won't cover Trimix. I was wondering if compounded medications were a common exclusion.

 

Gman

 

Unfortunately, yes, this is a common insurance hurdle. Trimix should not be terribly expensive though?

[+ g56whiz]

So it won't cover Trimix. I was wondering if compounded medications were a common exclusion.

 

Gman

My Humana covers my prescribed compounded testosterone thankfully cuz they offer very little coverage of Arndogel and the other variants. I suspect it’s more the Trimix rather than the compoundedness that’s the issue. I mean is there a medical necessity that you have sex?

[+ Gar1eth]

So it won't cover Trimix. I was wondering if compounded medications were a common exclusion.

 

Gman

 

My Humana covers my prescribed compounded testosterone thankfully cuz they offer very little coverage of Arndogel and the other variants. I suspect it’s more the Trimix rather than the compoundedness that’s the issue. I mean is there a medical necessity that you have sex?

 

The policy specifically states it doesn't cover compounded medications and never mentions Trimix at all.

 

If you don't mind me asking, why is your testosterone compounded?

 

Gman

[Strafe13]

I had a similar issue for a medication that wasn't related to sexual activity or function. My understanding, based on the pharmacist's explanation, was that it's rather common for insurance companies to just exclude compounded medications. I'm unsure why, but I take it that this is kind of the default rule, unfortunately.

Edited October 23, 2019 by Strafe13

[Chad Constantine]

Have you tried to see if trimex has a generic version. I was told that if my doctor prescribes me the generic version of my medication they will still send me the non generic version through the mail but I wont have to pay for anything. However if they prescribe me the non generic version of the medicine I would have to pay for it.

[+ BenjaminNicholas]

Have you tried to see if trimex has a generic version. I was told that if my doctor prescribes me the generic version of my medication they will still send me the non generic version through the mail but I wont have to pay for anything. However if they prescribe me the non generic version of the medicine I would have to pay for it.

 

Generic compounding isn't really a thing, as it's a specifically-tailored formula for that exact person. It should really always be done locally.

 

Also, would you really want to inject an off-brand compound, mixed in an unknown place, into your dick? Survey says... No.

 

So it won't cover Trimix. I was wondering if compounded medications were a common exclusion.

 

I bet that the insurance co will fallback on there being non-compound drugs that can get the job done. They'll also, as others here have said, say that functional sex is not a medical need.

 

I get that Trimix is about speed, but if you can learn to live with oral medications, you'll have an easier time staying covered.

[+ Gar1eth]

.

 

I get that Trimix is about speed, but if you can learn to live with oral medications, you'll have an easier time staying covered.

. I forgot to mention they don't cover pde5 inhibitors either. So even were they to cover compounded medications, they'd probably exclude Trimix too.

 

And thinking about Trimix wasn't for speed but because pde5 inhibitors don't always work for me.

 

Gman

[sincitymix]

So it won't cover Trimix. I was wondering if compounded medications were a common exclusion.

 

Gman

 

When a pharmacy submits a claim for a compounded medication, they must provide the NDC of every ingredient in the compound. if one ingredient is not covered the insurance can either : 1. deny the entire compound claim or 2. reimburse for only the NDC covered at the 100% discounted pharmacy rate... (which is NOT what you pay at the retail pharmacy but what the insurance feels is reasonable and justified).

 

Most insurances will also make you pay for the compounded medication and submit for reimbursement.

 

If a medication requires a mixture, chances are they will make you go through a PBM, and will send you both the active and inactive ingredients with instructions on how to mix them.

 

Check with the PBM or insurance to see if it requires a prior authorization or a PLA.. Patient level authorization.. have to show all the other medications that are on the formulary or are covered does not work for you... standards PBM red tape.

 

You might have a closed formulary.. those are the worst.. only medications on the list are covered, nothing else is period.. no authorizations or recourse no matter what you and the dr say

[+ Gar1eth]

When a pharmacy submits a claim for a compounded medication, they must provide the NDC of every ingredient in the compound. if one ingredient is not covered the insurance can either : 1. deny the entire compound claim or 2. reimburse for only the NDC covered at the 100% discounted pharmacy rate... (which is NOT what you pay at the retail pharmacy but what the insurance feels is reasonable and justified).

 

Most insurances will also make you pay for the compounded medication and submit for reimbursement.

 

If a medication requires a mixture, chances are they will make you go through a PBM, and will send you both the active and inactive ingredients with instructions on how to mix them.

 

Check with the PBM or insurance to see if it requires a prior authorization or a PLA.. Patient level authorization.. have to show all the other medications that are on the formulary or are covered does not work for you... standards PBM red tape.

 

You might have a closed formulary.. those are the worst.. only medications on the list are covered, nothing else is period.. no authorizations or recourse no matter what you and the dr say

 

The plan booklet says specifically that the policy doesn't cover compounded medications.

 

Gman

[sincitymix]

My Humana covers my prescribed compounded testosterone thankfully cuz they offer very little coverage of Arndogel and the other variants. I suspect it’s more the Trimix rather than the compoundedness that’s the issue. I mean is there a medical necessity that you have sex?

insurances will generally never cover something specifically for sex... chances are they will have the medication wrapped up under coverage that says only covered for prostrate problems.. ie cancer, surgery etc... but not for sex or sexual issues.

[sincitymix]

The plan booklet says specifically that the policy doesn't cover compounded medications.

 

Gman

that sucks. it is a hassle for insurances to go over compounded medication claims, but having dealt with them for 13 years.. people need compounded meds for so many reasons.. a 100 year old patient who could barely swallow anything solid, so compounding into liquid form was a life saver for her..

[Max]

insurances will generally never cover something specifically for sex... chances are they will have the medication wrapped up under coverage that says only covered for prostrate problems.. ie cancer, surgery etc... but not for sex or sexual issues.

 

While many consider sex optional or recreation, and not medically necessary, some do cover the PDE5 drugs (often limited to seven tablets per month). Fortunately, sildenafil and tadalafil are generic and very inexpensive (via GoodRx.com or similar).

[Guest]

My understanding is that Trimix was relatively inexpensive. Used to be cheaper than Viagra, Levitra, or Cialis.

[+ Keith30309]

I’m paying $300 for what is about a 60-90 day supply (I forget how many mL’s), but I buy it thru the compounding pharmacy used by my doc. I’m sure it’s available for less elsewhere but it’s really convenient. I make a call to my Dr, he writes the refill and forwards it on, they package and ship it and I have it in a couple of days.

It is *much* more effective than viagra for me.

[Max]

I’m paying $300 for what is about a 60-90 day supply (I forget how many mL’s), but I buy it thru the compounding pharmacy used by my doc. I’m sure it’s available for less elsewhere but it’s really convenient. I make a call to my Dr, he writes the refill and forwards it on, they package and ship it and I have it in a couple of days.

It is *much* more effective than viagra for me.

 

Might investigate options with GoodRx or other. Sometimes cheaper to pay cash for drugs in cash than to use insurance and there is often a huge price range for a given drug. For #30 generic sildenafil 50 mg tablets, range is $22 to $462 locally. Tried to insert screenshot but cannot figure out how to do.

[+ Gar1eth]

I’m paying $300 for what is about a 60-90 day supply (I forget how many mL’s), but I buy it thru the compounding pharmacy used by my doc. I’m sure it’s available for less elsewhere but it’s really convenient. I make a call to my Dr, he writes the refill and forwards it on, they package and ship it and I have it in a couple of days.

It is *much* more effective than viagra for me.

 

Might investigate options with GoodRx or other. Sometimes cheaper to pay cash for drugs in cash than to use insurance and there is often a huge price range for a given drug. For #30 generic sildenafil 50 mg tablets, range is $22 to $462 locally. Tried to insert screenshot but cannot figure out how to do.

 

I just entered Trimix into GoodRx and nothing came up. I'm not surprised. Since it's compounded from three different medications, GoodRX doesn't really cover that kind of thing as far as I can tell.

 

As for inserting a screenshot, you can't insert pictures directly into the Forum. Except for our personal icons, they have to be hosted on the web somewhere. For personal pictures what I do is -

 

1. Take the screenshot

2. Upload it to Dropbox

3. Get the link from Dropbox

4. Post the link in the Message Center Picture Function.

5. There's a small modification you have to make. The initial Dropbox link leads to some kind of in between page which the Forum software can't handle. When you post to the Message Center, change the last part of the picture link to raw=1 from the dl=0 that Dropbox gives you.

 

For posting web pictures, I use the Chrome Browser. There you click (or press if using your phone) until you get the option 'Open Image.' Choose that and copy the link. Then post that link in the Forum picture function.

 

Gman

[Max]

I just entered Trimix into GoodRx and nothing came up. I'm not surprised. Since it's compounded from three different medications, GoodRX doesn't really cover that kind of thing as far as I can tell.

 

As for inserting a screenshot, you can't insert pictures directly into the Forum. Except for our personal icons, they have to be hosted on the web somewhere. For personal pictures what I do is -

 

1. Take the screenshot

2. Upload it to Dropbox

3. Get the link from Dropbox

4. Post the link in the Message Center Picture Function.

5. There's a small modification you have to make. The initial Dropbox link leads to some kind of in between page which the Forum software can't handle. When you post to the Message Center, change the last part of the picture link to raw=1 from the dl=0 that Dropbox gives you.

 

For posting web pictures, I use the Chrome Browser. There you click (or press if using your phone) until you get the option 'Open Image.' Choose that and copy the link. Then post that link in the Forum picture function.

 

Gman

 

Thanks. And I tried to drag into the message box. LOL.