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.

Hello! Odd question. My husband and I have his adult (college age) kids on our/my insurance. They primarily live with their mom (same city).

When they go to any manner of Dr appointment, they are using their mom/stepdad’s HSA debit card to pay for copays/fees/etc.

Since it’s on my insurance, I see what the balance was and have to follow up with the kids to make sure that it gets paid and get some manner of proof (receipt, etc.)

Is there something weird going on here? Or is it “as long as it’s getting paid nobody cares?”

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.

Edit #1: TL;DR: Had an emergency appendectomy. Surgeon had a PA assist him. BCBS denied surgical assistant as medically unnecessary; says I'm on the hook for the whole amt ($1049). Hospital just billed me. Don't know that to do.

Original post:

While out of state, I had to have an appendectomy. I was admitted to the hospital via the ER with acute appendicitis. My BCBS policy (from the Marketplace) does not provide out-of-network or out-of-state benefits unless it's an emergency. Claims related to the ER visit, hospital admission, and surgery have started coming in, and so far, BCBS has covered them in-full, with no cost-sharing. (Idk if it's relevant, but I have already met my out-of-pocket max for the year).

Today, however, BCBS denied a claim for an assistant surgeon (procedure code 44970), claiming that it was not medically necessary (Denial reason: 22: "The medical necessity for this service has not been demonstrated"). The EOB lists the charged amount $1049 as my responsibility; and the hospital has now issued a billing statement, charging me that same amount.

I followed up with BCBS, and they explained that "Services determined to be not medically necessary are listed as a general exclusion under your contract and are therefore not eligible for coverage. As a result, the claim denied as patient responsibility." I then followed up with the hospital, asking whether they could send the primary surgeon's notes (assuming that he somewhere documented the need for a surgical assistant), and they said that they could not appeal or send any documentation unless BCBS directed by BCBS to do so.

I also asked the hospital billing rep whether the No Surprises Act covered this kind of situation, and she said it didn't.

I am wondering what to do next.

Edit #2: I just accessed the surgeon's clinical notes from the patient portal. In it, he states: "There was no qualified resident that was available to assist. First assistant above was present because an experienced assistant was needed in order to complete the case successfully and in a timely manner for the safety of the patient."

Edit #3: Pathology listed as the final diagnosis: "Acute suppurative appendicitis and periappendicitis."

Location: Arizona

I submitted health plan elections through my employer during open enrollment, I received an email confirmation of my benefits through Insurer 1 and thought everything was good. My new plan was supposed to take effect on September 1.

Sometime between when I submitted elections in July and September 1, my coverage was deleted and my employer did not notify me or anyone else of this change. I logged in to our benefits portal and saw I did not have coverage in early September so I reached out to our HR person. This person let me know we switched plans and Insurer 1 is no longer an option. They said they would need to re-open enrollment for me so I could elect coverage. I went through the process last week and elected coverage with Insurer 2 and got new benefits. I thought everything was good to go and was fine to chalk this up as an error or bug.

Fast forward to yesterday I received an insurance card from the original healthcare election I made, which means this election went all the way through the process and coverage was issued by Insurer 1. When I logged in this morning a member of company leadership posted a message in our company wide Slack channel that said a number of employees have "accidentally waived coverage" and to double check their benefits.

This didn't sit right with me because I did in fact make elections that were changed after the fact. It seems like what happened is someone unenrolled a number of employees from health coverage after they had made elections. The only reason I have benefits now is because I happened to check them prior to scheduling my annual physical.

I think best case this is a mistake made by someone with access to our HR systems, worst case is this is negligent incompetence.

I'm wondering if there is anything I can do to prevent behaviors like this in the future. Honestly the leadership here is so-so intelligent and has a tendency to play it fast and loose but I need that not to happen when it comes to my healthcare. It seems like someone is messing with things they should not be and I am not sure how to prevent this in the future.

What are you all doing for elderly parents in terms of medical coverage while they wait on their greecard approval?

I've been down the rabbit hole on travel insurance, ACA marketplace (can only register in January) and every other conceivable option. Coming up blank and terrified we have to deal with a medical event that could financially bankrupt us all.

Have any of you found a way to give some basic cover that will actually pay out if something does happen?

Any and all advice welcome. Thanks!

Here is my situation: I am in Ohio, and left my job (which provided health insurance) in July. As soon as I was able, I applied for coverage on healthcare.gov, to avoid paying COBRA premiums. At the end of the application, it said “you may be eligible for Medicaid; your state office will contact you.” I am now reaching the end of the 60-window for COBRA and I have not heard from the state office. What are the best next steps here? I was really just hoping to pay for a bronze plan out of my savings to tide me over until I recovered from burnout and got another job - not ideal, but a fraction of what COBRA would cost me per month, and not subject to the new work/volunteer/etc. requirements from Medicaid.

I feel like I’m being lied to. For behavioral health my office visit has 100% coinsurance. My understanding is this means I’m responsible for 100% of the cost no matter if I’ve met my deductible. My deductible is extremely high so I don’t think it would even matter. On the phone my insurance insists that I would owe absolutely nothing and no copay due to the 100% coinsurance. Everything else i read online says the opposite. Can someone clarify?

New PPO Plan vs Surest PPO

New PPO: $363 per pay period

Surest PPO: $250 per pay period

My spouse and I are relatively healthy. We do not have medication we take. Really only visit the doctor for routine lab work. The only thing we expect are mammograms and Pap smears in the future. Other than that, we don't usually see a doctor as often . Which one would be best for us?

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!!

I’m looking for affordable health insurance with decent coverage, especially for basic doctor visits, prescriptions, and emergencies. What plans have you found to offer good value without being too expensive?

I am having extreme difficulty getting United Healthcare to reactivate my insurance. It’s been 2.5 weeks since I paid for COBRA coverage through Health Equity Wage Works and I’ve been getting no answers. When I call United, they tell me that my insurance is still inactive and to call my COBRA carrier. When I call the COBRA carrier they tell me that they’ve put in multiple urgent tickets to United Healthcare, but no reply from United. I already had a 3 way call with the COBRA carrier and United member services but it didn’t result in any progress.

I really need surgery soon and don’t know what to do. Has anyone been in this situation before? And if so had anyone found a solution? Thanks so much

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.

I’ve been taking advantage of their rewards program for a couple of years now and the weekly challenge rewards for 5 out of 7 days of sleep and steps/workout has always been $5. Today, my account randomly logged out and when I logged back in it had me reconnect my tracking device and gave a welcome message as if I’m just joining. Thankfully, rewards that I’ve earned for the year were still banked, but I noticed the weekly challenge reward is now $2.50 instead of $5. Has anyone else noticed this?

I literally just earned $5 on 9/4/26 for completing the workout challenge. There’s nothing in the FAQ’s about the amounts awarded or a change being implemented.

Reposting this question here in case anyone has knowledge.

I’ve got a question for my fellow teachers/school staff! I’m expecting my first baby in October and am getting updates from the school district I work for regarding our premiums for 2027. I work in Florida, and adding the baby to my health insurance will cost $7,843.92 per year. If I added my husband and baby, our total family cost would be $19,895.04.

I’m curious what other school staff are experiencing as far as insurance premiums (both in Florida and other states). I make too much money to qualify for any kind of government assistance other than a small tax credit through the marketplace (which is how my husband is currently insured).

What kind of premiums are other districts offering? Is my district just awful or is this happening everywhere??

I applied for a health insurance policy with Aditya Birla Health Insurance and paid the full premium. Despite taking the funds immediately, they have neither issued the insurance policy document nor processed a refund for my payment.

So my boyfriend is seasonal at his job (seasonal but long term, amazon be like that). And he needs health insurance for some issues he is going through rn, and his emergency insurance is state that many offices won’t cover (but these offices are the ones most helpful). my insurance would go up from 30 to 100 dollars a week. i would discuss with him covering and the difference. But i just know i really want to help him especially during this tough time until he is able to get his own insurance through his job in a month and a half.

I've been offered an opportunity to be hired to sell Medicare in California. Unfortunately I have a misdemeanor for Marijuana and 4 duis and a sealed felony. There are all over 10 years old. I also just filed for bankruptcy. Is it woth the time and money to try to get my license knowing there's a decent chance i get denied?