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How can an insurer just decide they will not cover/pay for a medication?
Posted on 3/16/22 at 3:38 pm
Posted on 3/16/22 at 3:38 pm
Your doctor prescribed a certain medication and the insurer has paid for it for years. Then one day they deny it and tell you to take something else. Not a generic, just something else. WTF is that all about? You contract with the insurer and they just change the rules or terms? Doesn't seem right.
20
Posted on 3/16/22 at 3:40 pm to Jimmy2shoes
quote:
contract with the insurer and they just change the rules or terms
Posted on 3/16/22 at 3:41 pm to Jimmy2shoes
Contract is renewed every year. You can always opt out if you want another carrier.
But yes, insurance exists to make money, not serve the greater good.
But yes, insurance exists to make money, not serve the greater good.
Posted on 3/16/22 at 3:42 pm to Jimmy2shoes
Formulary must have changed. Or maybe the PBM changed
This post was edited on 3/16/22 at 3:43 pm
Posted on 3/16/22 at 3:43 pm to Jimmy2shoes
Each year your insurance company reviews and changes their formulary. That is the list of drugs they deem appropriate for coverage. Drugs move on and off that list. It could very well be that the drug you are on has moved to a higher tier or been removed from the formulary because it is too expensive in the eyes if the insurance company.
There are appeals processes in place and your doctor can submit a statement of medical necessity. That is, a description of why this specific drug is the one you should be on. That might be enough or they could force the issue and make you do trials with a different drug before agreeing to pay for the cure one again.
There are appeals processes in place and your doctor can submit a statement of medical necessity. That is, a description of why this specific drug is the one you should be on. That might be enough or they could force the issue and make you do trials with a different drug before agreeing to pay for the cure one again.
Posted on 3/16/22 at 3:47 pm to Wiseguy
quote:
Each year your insurance company reviews and changes their formulary.
It is quite the process involving kickbacks between the various parties.
Posted on 3/16/22 at 3:51 pm to Jimmy2shoes
It’s that fricked up system that we created to allow non medical people to take the profits out of medical industry. basically a new york tax on everyone else
Posted on 3/16/22 at 3:51 pm to GetCocky11
quote:
It is quite the process involving kickbacks between the various parties.
I know for a fact that this happened with Caremark. They got a kickback from Trintillex and now they won’t cover other similar meds. Your doctor can actually do a peer to peer to appeal the decision.
Posted on 3/16/22 at 3:55 pm to Jimmy2shoes
Also possible that the drug was previously approved as a formulary exception and the plan decided to not grant the exception anymore. That's less likely because you'd probably already know if given an exception.
Maybe there is a drug that is know covered that is newer to the formulary and they want they tried first. It's frustrating because you had something that worked.
Maybe there is a drug that is know covered that is newer to the formulary and they want they tried first. It's frustrating because you had something that worked.
This post was edited on 3/16/22 at 3:58 pm
Posted on 3/16/22 at 3:56 pm to Jimmy2shoes
Pull back the curtain… they’ve consolidated to just three PBMs who control 80% of the market & are owned by the insurers…
Perverse incentives
Perverse incentives
Posted on 3/16/22 at 3:58 pm to GetCocky11
quote:
It is quite the process involving kickbacks between the various parties.
Trip to the Maldives is not going to pay for itself...
Posted on 3/16/22 at 3:58 pm to Jimmy2shoes
Most insurers publish a list of what medicines they will pay for. Check the list.
Posted on 3/16/22 at 3:59 pm to Funreaux
Express Scripts, CVS, and Optum?
That preferred status doesn’t come cheap and we consumers pay the price for it.
That preferred status doesn’t come cheap and we consumers pay the price for it.
Posted on 3/16/22 at 4:00 pm to GetCocky11
quote:
is quite the process involving kickbacks between the various parties.
If you need to raise your blood pressure a few points, read up on Pharmacy Benefits Managers.
Posted on 3/16/22 at 4:03 pm to Jimmy2shoes
Or certain dosages are covered while others are not. My wife was on something a few years ago, and they came in 10, 20, or 30 mg pills. Insurance would cover a 20 mg once a day, but would not cover 10 mg twice a day. Literally the exact same daily dose, but this wasn't a time released medicine. She had side effects to taking 20 mg in the morning, but could handle the 10 mg in the morning and evening better, so we had to go round and round with the doctors and insurance for them to cover the twice a day dosage. If they were tablets we could have just gotten the 20s and split them, but they were only made in pill form.
Posted on 3/16/22 at 4:04 pm to Jimmy2shoes
Because frick YOU! What are you going to do about it?
Scumbags.
Scumbags.
Posted on 3/16/22 at 4:11 pm to Wiseguy
quote:
Each year your insurance company reviews and changes their formulary. That is the list of drugs they deem appropriate for coverage. Drugs move on and off that list. It could very well be that the drug you are on has moved to a higher tier or been removed from the formulary because it is too expensive in the eyes if the insurance company.
There are appeals processes in place and your doctor can submit a statement of medical necessity. That is, a description of why this specific drug is the one you should be on. That might be enough or they could force the issue and make you do trials with a different drug before agreeing to pay for the cure one again.
This!
I went through this and with my Dr. jumping on the completion/submission of the insurer's justification form, the insurer approved the use with same 1st tier co-pay for 12 months. Will have to file justification once a year it appears.
If you ultimately can't get it approved, there may be a good substitute drug on the formulary.
Also, my doctor worked-out a 3 month supply from Walgreens at $0 cost to me, so my drug supply is reinforced. I dont qualify for discount programs, so nor sure how they did it.
Finally, your dr. may have generous amounts of drug samples to help you out.
This post was edited on 3/16/22 at 4:13 pm
Posted on 3/16/22 at 4:12 pm to Jimmy2shoes
quote:
You contract with the insurer and they just change the rules or terms?
Posted on 3/16/22 at 4:38 pm to Jimmy2shoes
quote:
You contract with the insurer and they just change the rules or terms?
This guy hasn't read the contract.
Posted on 3/16/22 at 4:40 pm to Jimmy2shoes
By the time you win a lawsuit about it you are dead
Therefore
You have no choice
Therefore
You have no choice
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