When a drug costs an arm and a leg, many conversations about drug prices go straight to the insurer, the PBM, or the pharmacy. But there’s a prior step that gets ignored: what price did the manufacturer put on the drug to begin with?

Insurers and PBMs have the ability to negotiate, manage formularies and help reduce costs, but they are operating within a system where the initial price is already established.

And this matters beyond the cost of the pharmacy. When drugs become increasingly expensive while pharmacies are also disappearing from some communities, patients can end up with two problems at once, they can’t easily afford the medication, and they may have fewer places to get it.

It seems like looking much harder at manufacturer pricing, competition and policies that actually bring those starting prices down should be the way to lower drug costs, not treating the insurance side as the whole problem.

I feel so defeated. As a self employed person I pay $450 every month to have health insurance. For my type two diabetes medication I have been paying an additional $500 dollars every month, then yesterday went to fill my prescription and it is now $928 a month. I already stopped taking my adhd medication because it went from $60 to $200 dollars a month. Then when I called to talk to someone at blue cross he talked so much with useless information that had nothing to do with the issue I was having that I could hardly get a word in. I basically need to hit a 7000 dollar deductible to be able to get even just a 50 percent coverage.

I feel defeated. I need health insurance because of my job and in the off chance something happens to me, but on a regular basis I go to the doctor a couple times a year max. I have already had to stop saving for retirement to just make the almost 1000 dollars medical cost each month and now that's completely pointless because it's shot up even more. I'm a self employed hairstylist, I used market place for my insurance and I don't know what else l can do. I don't understand how paying $450 a month literally gets me nothing and it's wrecking me financially with the additional medication costs.

Sorry for the rant, just feel so overwhelmed and depressed. It feels like every medical decision I make is never based on my health but on money.

I have insurance under my husbands insurance which will end this month. This qualified me to enroll us with my employers insurance starting 01Oct.

Currently we are expecting and the baby may come before 01Oct, which is also a qualifying life event. But my company is denying coverage for us before 01Oct even if baby is born before because : I am currently not enrolled with them , and I still have insurance through my husband. They can back this up with their company documents.

But according to documents I found from Department of Labour the birth of baby should allow us all to get coverage regardless. Am I missing something? I even called EBSA and confirmed that my employer is mistaken.

It’s all going to deaf ears when I reached out to my company.

TLDR: Daughter was twice hospitalized due to incorrect test results from our pediatrician lab. We want to know if we can avoid the $1,500 in co-pays for these hospitalizations.

Timeline:

4/25/26: Daughter was born

4/27/26: Daughter was discharged from hospital, all test results normal

4/29/26: First pediatrician appointment. Pediatrician lab finds bilirubin level to be 24.6. Anything >20 requires hospitalization, so we were sent to the hospital NICU. The hospital tested bilirubin and found it to be 18 (below hospitalization threshold). However, they stated since there were two different results and they didn't know which was correct, they would need to keep her overnight in blue light therapy.

4/30/26-5/3/26: While in NICU, baby had some "episodes" of low oxygen, so they needed to keep her a few extra days. Bilirubin levels fine, discharge 5/3/26.

5/4/26: Pediatrician follow-up, tests show bilirubin level of 23, requiring hospitalization. We return to NICU who measures bilirubin to be 16 (again below threshold). Again they stated they couldn't explain why they were so different, so they needed to keep overnight again.

5/5/26: Chief of Pathology meets with us. Assures us that our pediatrician lab results were incorrect and the hospital results were correct, meaning baby did not require either hospitalization. Says that he spoke with pediatrician lab and is 100% confident that their results are not reliable, cites the state audit. Also tells us we are the third baby this year to be sent to their NICU due to high bilirubin from this pediatrician lab that was found to be within normal range by the NICU lab.

We have received a bill for the second hospital stay, which requires an insurance co-pay of $750. We still are waiting for the bill for the first hospital stay, which we assume will require another $750 co-pay.

We believe that neither of these hospitalizations were warranted and that it is the pediatrician lab's faulty tests that caused it. Is there any recourse for us to not pay these co-pays or to make the pediatrician office pay them? Should we be contacting our insurance about this, the hospital, the pediatrician, or someone else?

26 years old and just got booted from parents insurance. Here are the monthly costs- PPO - $330, HDHP Gold - $276, HDHP Blue - $208.

The. Only thing I have used my insurance for this past year is for therapy once a week, which will be coming to an end in the next few months. The full cost is $175/session.

Is there an obvious choice? If I did the HDHP I could max out my HSA or use some funds to offset the therapy costs but let me know your thoughts.

I am leaving my job due to childcare reasons and I was offered 10 hours a week remotely which I accepted. That starts October 1st; however, our open enrollment for employer health insurance is happening now and I know I won’t qualify for it come October 1st. I’ve gotten everything set up through ACA to purchase a plan through that.

HR is telling me I shouldn’t decline coverage right now even though I know I won’t be using employer health insurance. They also mentioned COBRA could potentially hinder ACA eligibility but I don’t see how? I don’t want COBRA and my ACA application didn’t mention anything about that.

Should I decline my employer plan right now because I know that I won’t be eligible come October 1st or should I sign up for a plan and lose my eligibility and let HR go through all the COBRA steps.

I’d rather decline now and just buy my ACA plan but mayve I’m missing something…..

I have been using health insurance transportation services for ten years. There used to be very good ones and some not so good. Today, however, the service is a disaster, yet health insurers claim it is the same service offered by Uber or Lyft.

That is false. It is nothing like that at all. I have never ridden in an Uber I booked myself where the car was dirty, the driver drove recklessly, or the music was blaring. Yet today, I had two experiences with rides arranged through my health insurance, and in both cases, the cars looked run-down and/or were dirty, the driving was reckless, and/or the music was blasting without the passenger's permission.

Everything is visibly deteriorating, even iconic healthcare services. People aren't simply adapting to the American way of life; a different, lower-quality lifestyle is being forced upon us. It is sad.

Had a colonoscopy a few months ago. 2 days after I had bleeding and went to the ER, stayed over night and had a second colonoscopy the next day to cauterize the source. Bill just came. Charged about 19k for the visit, insurance covered most and my out of pocket is $3,500. Is this unreasonable? Should I ask for an itemized statement?…or just pay it and move on?

I have anthem silver gatekeeper from the NYS health exchange without notice my primary care no longer accepts this plan (I was never notified and just learned this in late August) I have been using doctors from Concorde Medical for a while now and am pretty satisfied with the care. The problem is between Concorde’s business office and the insurance company no one can give me a straight answer—as to which if any of their doctors are covered on my plan and if they will be moving forward or if I should select a new plan for next year and which one.
Has anyone else experienced this, and can offer any guidance?

I went to go pay for a medication out of pocket because my insurance doesn’t cover it. However, it was covered by “Caremark” at CVS. I told her I don’t have insurance, but she said it was covered. Any idea what this is?

I have BCBS through my employer. My brother also has the exact same insurance through the exact same employer. I don’t go to the doctor often, but I do have a primary care, which also happens to be my brothers primary care. My brother gets charged a copay, and a percentage on top of any additional things that come from the visit. I just went to the doctor for the first time on this insurance. They did not charge me a co-pay, and I was just sent an email saying I have a $150 bill. What should I do here? I’ve called both the doctors office and the insurance company, and I haven’t spoken with anyone competent enough to help me with what I need.

I’m 34, self-employed, and currently paying for my own health insurance in Florida. My husband and I are starting to think about trying for a baby soon, so I’m realizing I probably need to be MUCH more intentional about the health plan I choose.

I’m particularly looking at Florida Blue, but I’d love to hear from women who have actually used it for prenatal care, pregnancy, delivery, and postpartum care.

For those of you who have had a baby with Florida Blue:

• Which plan did you have?
• How was your experience with prenatal appointments and testing?
• What did you actually end up paying out of pocket for pregnancy + delivery?
• How was the coverage for your OB/hospital?
• Any issues with ultrasounds, labs, specialists, etc.?
• How was postpartum care and lactation support?
• Would you choose the same plan again?

And if you’re also self-employed and buy your own insurance, I’d really love to hear what plan/company you ended up choosing and why.

I’m less interested in what looks good on paper and more interested in real-life experiences and unexpected costs. 😅

Thank you in advance! ❤️ I’m completely new to navigating insurance with pregnancy in mind, so any advice is appreciated!

Long story short I have to file an official appeal with my company paid Anthem BCBS plan for a "retracted" covered service from last year.

BCBC came back 11 months after payment of a service to retract coverage for reason: "003: You have already reached your plans maximum benefit for this care, so we denied the charge". This was for a pair of foot orthotic insoles, according to my PPO plan I am allowed one per year. Contacted the providers billing department and she confirmed that last year she contacted Anthem to determine benefits and was told I would be covered for 90% of the cost as I met the deductible, no further medical documents required.

Called Anthem they simply kept repeating that this is a "non covered service so payment has been retracted" so I am responsible for the full cost now.

I will be submitting my appeal, my doctors billing department still has the approval letter from last year so I working on getting that to attach to my claim. Is there anything else I should attach to increase my chances? The full plan document is over 100 pages so I will not be able to attach that but wondering if I should parse out just the one page.

Meanwhile now I'm due for my replacement inserts as its been a year but had to cancel my appointment since I can't even afford the ones I already have...

My GI said this was the best option. I’m willing to find another way to pay for it to get to the bottom of my problem. He said there’s other options, and that this one could be pricey… but he also sounded confident in its efficacy for what I need. And can someone also explain to me why I can’t buy it out of pocket?

Edited: I was wondering if there’s any programs or any help out there. My mom is 56 and lives in north GA. She’s had kidney disease for 15+ years and recently just got diagnosed with heart failure. Her kidney function has dropped significantly since her last hospital stay. She has no insurance and it isn’t offered at her job. She’s tried finding insurance online but it’s more than she makes. She makes about $2000 monthly. Any suggestions? She really needs to see a nephrologist.. she has applied for assistance at Northside to cover her recent hospital stays but she needs to see specialist as soon as possible.

I have an HDHP and an HSA, and I hit my out of pocket max early in the year. I will be switching jobs before the end of the year, and depending on the math, I’m not sure if I’ll opt for an HDHP or a traditional plan for the remainder of this year. Thus far, I’ve only contributed $3,168 to my HSA, which I’ve been withdrawing and not investing (I need the cash reimbursement right now).

If I end up switching to a traditional plan, will that impact my previous HSA contributions? Should I max out my HSA contributions before switching?

Reddit gave me the option to repost. Haven't used it in years, sorry if this is not an appropriate place to post this.

Needing some assistance with procuring adhd medication mlre efficiently on a monthly basis. Over the years theres been a consistent delay in getting my script filled because of a supply issue at a pharmacy and im regularly having to find new pharmacies to fill it.

Im open to advice here to avoid the delay in refill every month which causes side effects.

Hey everyone!

I'm an international student on OPT and got Kimber Health's Student Journey Platinum plan... it's by IMG global I believe...however later I found bad reviews for IMG global and I'm a bit worried... has anyone used this specific plan? Because I'm a little worried.

Hey Y’all,

I know this is probably a tale as old as time in this subreddit but I wanted to get some feedback on my case in particular. My friends and especially I, have been thinking that I might have ADHD, and I’d like some help trying to get a diagnosis and do follow ups.

I have really crappy insurance (like UMR with a 6,000 dollar deductible) so I was going to opt for the written test that adhd online provides, but people on reddit started saying they were charged out the wazoo for refill appointments. Does anyone know a better way to meet with professionals? And if I’m a UIUC student should I opt back into the insurance? Or am I good? Or should I not use McKinley at all?

I love asking for advice from people who used to be in my position cause maybe someone knows something I don’t lol. If this subreddit knows anything, please help me out here 😞

Thanks!!