RE: Formulary

November 8, 1999

So they suddenly and arbitrarily remove meds from them? Without even notifying

the insured? (Thanks for that info, I am woefully ignorant on such things and

insurance company hoo-haw always leaves me bumfuzzled!

[ ] formulary

The formulary is the list of medicines that your health plan or insurance

company uses or pays for.

November 8, 1999

Kay,

Your insurance company wouldn't be Prudential or Aetna, would it?

HMOs use a drug formulary, in other words, a list of drugs that they will

cover at the lowest co-payment. Almost always they are generic drugs and

not necessarily the best available (but often are). There is an additional

list of " approved " brand name drugs, available at a higher co-pay. Again,

they don't cover all of the drugs that might be best available.

Anything that's not on either the generic or brand name list isn't covered

without going through a long process that isn't always successful. Also,

some drugs that have only been FDA approved for a specific condition for a

few months might not be approved at all.

Here's an example of how it works:

Your doctor prescribes Prilosec. It's not on the generic or brand name

list. Your doctor has to contact the Formulary Unit center and justify the

reasons he wants you to take that drug. Sometimes they use a " step "

procedure. In other words, it has to be shown that you've been tried on

one or two or more other similar drugs and they didn't do the job. For

example, for Prilosec, they might say you need to try Cimetidine first and

if that doesn't work, try Pepcid next. If that also doesn't work for you,

the doctor has to tell the insurance company that you need something else

and ask for Prilosec. In our case, this is what happened and the insurance

company said " No Prilosec. Use Pravacid instead. " They then approved

Pravacid.

Here's the deal and insurance company hate for us to suspect this: They

get big discounts from some pharmaceutical companies and less from

others. They also have contracts with some pharmaceutical

companies. Prilosec is made by one company but the makers of Pravacid has

a contract with the ins. co., so the insurance company gets deep discounts

and that's the drug they will insist you use. If you have a doctor who

isn't worn out and burned out by this time, he or she might go to bat for

you and insist that only Prilosec will work. In my case, I had a problem

with Pravacid - it can aggravate acid reflux in some people and it did

something to me that caused nausea.

But, your insurance company is changing the rules of the game in the middle

of the match. Ours tried to do that too. And, this is what I did:

I photocopied my receipts for drugs I'd been taking for a year or more,

that were approved by the insurance company for that entire year. I then

sent a letter to the corporate offices of the insurance company asking them

to justify what they were doing (denying drugs they'd been approving for

godzillion months). I sent a copy with a cover letter to the Head of Human

Resources at my husband's employer and I also sent a copy with a cover

letter to the Insurance Commissioner for the State of Texas, where

Prudential is based. Within 3 working days the s * * t hit the fan and we

got calls from my husband's employer, the insurance company and the

Insurance Commissioner's office. My husband's company is going into the

problem big time because we aren't the only ones who have had

complaints. The Insurance Commissioner will investigate the complaint and

whatever their findings, the complaint is now a matter of record (insurance

companies don't like that). AND, the insurance company gave us a wishy

washy excuse that " since you've been taking those drugs for so long we've

decided to approve them.

The interesting thing about all of this is that we are NOT on and HMO and

shouldn't have been subject to a Formulary Unit approval in the first

place. Our plan covers all drugs, generic or brand name, without

restrictions. However, Aetna (the biggest and one of the worst rated

health insurance companies in the US, I've been told) has just acquired

Prudential and I suspect that they're thinking they might be able to

administer their PPOs like they're HMOs.

You need to contact the Formulary unit at your insurance company, find out

their direct number for your doctor's office to call, and your doctor

(probably his nurse or administrative staff) then must make an official

request for approval of the specific drug you've been taking and need. The

request will require justification. It's a big pain in the fanny and can

take weeks if everyone doesn't stay on top of it. If that doesn't do it,

tell them you want to appeal their decision.

In my opinion, if each of us were to file complaints with our insurance

commissioners when we're jerked around this way, things will change. If

you have medical problems because of being deprived of the meds you need,

document them if only in your own records. If our insurance company

continues to play games with us, we'll tag onto a class action or find a

lawyer to handle the situation. Just write letters, letters,

letters. Document everything and even send them certified, return receipt

requested, so they can't claim they didn't get the letter. Insurance

companies aren't doing us favors. We are buying a service and we are

entitled to get what we paid for.

Today there was a news report that the largest HMO in the US will no longer

supercede their physician's medical decisions, including prescribed

drugs. The writing is on the wall. HMOs know it's just a matter of time

before patients can sue for damages and by putting the onus back on the

doctors, they can dodge the thousands of suits that surely will

follow. Expect to see all or most insurance companies to follow suit (as

above) in the near future. I hope it's soon enough for all of us. It's

our lives they are playing with.

Take care,

Geri

November 8, 1999