Thought I'd give a little tutorial on insurance & prescriptions, since there's always a lot of misunderstanding or no understanding at all regarding what drugs they cover & how they come up with their list.

Before we all start bashing insurance companies, let's all remember something - insurance companies are not charities. Most of them are public companies like General Motors or Microsoft that have shareholders who demand they maintain a certain level of profitability. I have stock in Health Net, they've helped my retirement account quite a bit. :D And the main purpose of insurance is to spread the risk of financial loss among a large group of people... not pay for every medical expense you ever incur.

There are still a few "nonprofit" organizations out there, I think. At least there were when I was still in the industry. Blue Shield of CA was one... all they had to do was charge enough in premiums to cover claims, and pay fat salaries to their execs. :eek:

Moving on...

If you aren't aware, insurance companies can't afford to pay for any and all drugs out on the market. The way pharmaceutical companies are out there pushing their pills on physicians & the public, the rate of prescriptions issued has skyrocketed in the last 15-20 years. And anti-depressants are a big part of that.

So, what they do is encourage the insured folks to buy generic medications by giving them a low copay. However there aren't always generics available. Or sometimes the physician specifies brand name only, so the insurance company picks one or more from each drug classification and says "Okay, John Q. Insured... here's a list of more expensive brand-name drugs for you. We'll still cover them, but you'll pay a little higher copay". And if you want a drug that's not on their list, they say "Okay, Johnny... we're still going to help you, but you're gonna foot most of the bill for this particular drug". If you're on an HMO, they say "Johnny, you're on your own here". Usually, your doctor knows or can check if a prescription he's about to write is on your plan's formulary list or not. You can also request a copy of that formulary list. They're usually revised annually or semi-annually.

BUT - sometimes there's a drug that is not on that formulary list, however there's a legitimate medical reason why your doctor says you must take this medication instead of one of the others on the formulary list. Most insurance companies will then treat that drug like it is on their formulary list. Of course, they don't tell you that. They can't... it's not something they can write in their literature, its something they have to review on a case-by-case basis. And most agents are too dumb to know also. Or they're the type that when you call they give you the 800 number to the insurance company. I hate insurance agents more than I hate insurance companies. Mental/nervous disorders and their respective prescriptions, however, aren't good candidates for this special treatment.

I had the opportunity to meet with the head of PacifiCare's "prescription dept" about 8 years ago. I can't remember if he was a physician or pharmacist, but there were a whole team of physicians & pharmacists assigned with the task of creating & managing their formulary list of medications. It was so interesting... this was an official meeting, but he was very candid and answered all our questions directly and honestly.

He said that they don't always choose the cheapest brand name drugs in a classification for their formulary list. They do look at the cost, but they spend more time researching each drug, it's history, if it's compound is similar to others in that classification, etc... they don't want to pick one drug that's a little cheaper, but that has a lower efficacy than the other medications. That could potentially cost them more in the long run. They also consider how long a drug has been on the market, if there's a generic available, or if the drug patent is close to expiration.

This is where I learned that they will cover medications not on the formulary list. Also, I learned that the pharmacist has a lot more power/clout with the insurance company. At least with PacifiCare, the pharmacist could intercede for the patient & request a non-formulary drug be dispensed at the formulary rate.

This is where I learned that they will cover medications not on the formulary list. Also, I learned that the pharmacist has a lot more power/clout with the insurance company. At least with PacifiCare, the pharmacist could intercede for the patient & request a non-formulary drug be dispensed at the formulary rate.

Thanks! That was very informative. Always good to get recon from the other side (Okay they are supposed to be on our team but most of the time it sure doesn't feel like it).

I am all for Capitalism (although in a perfect world...medical care would not qualify as a for-profit venture) and understand the companies have stockholders to answer to. That being said as I said above....the fact that we operate in this fashion is dismal commentary on the state of humanity. I have always been incensed when the insurance company put the kibosh on something my doctor deemed a necessary part of my healthcare. Call me crazy but I feel that my doctor (who has attended medical school) and who has known me for years, and me (who has not attended medical school but takes great responsibility for my own healthcare) and has also know me for years (almost 40 to be exact) have the tools necessary to make much more accurate decisions about what is in my best medical interests over an insurance company that makes very impactful decisions over a weekend expo at the Ritz Carlton (many of whom DO NOT have medical degrees) and in the end the bean counters have final veto power anyway (all MBAs here). That being said, it doesn't escape my attention that they are firmly sandwiched between us and the pharmaceutical companies who I have no love for either. Even though production and R and D is expensive....there is a LOT of waste and they have HUGE margins. Call me picky but I find it unethical for anyone in the medical industry to be striving for Bill Gates-type dough and we should be ashamed we don't have legislation preventing it.

Referencing the above line (and just my own personal experience) the whole pharmacist as liason idea is not comforting to me. I have experience A LOT of either unintentional ignorance OR intentional deceit (if given the choice I surely hope it is the latter) on the part of pharmacist in regard to ADHD stimulant meds. This is even more perplexing because I have encountered this issue in a large progressive city over a cross-section of age groups in pharmacy personnel. The problems have run the gamut from being given inaccurate and very easily verifiable DEA reg data (namely that you MUST see your DR in person for a regular session each time you get a new script - false!) to being interrogated about a prescribed dosage that is higher than the boilerplate recommendation (I DIDNT WRITE IT - MY DR DID OK!!) to overall prejudice about ADHD and stimulant med therapy in general, which is odd because to me this is like your PCP turning you away and telling you to seek out holistic medical treatment instead. Soooo I'm not gonna sign my pharmacist onto the team anytime soon.

BUT....thanks for the information...finding out how they think and make decisions is useful and informative.

Very well put. It's a thought train you can get stuck on forever. Eventually, you just have to say "Screw it" and get off, otherwise you'll go nuts.

Re: insurance companies, what really turned me was how they'd speak out of one corner of their mouth & tell the people "times are tough... the cost of medical treatment in the U.S. is rising... the amount of usage by you folks is going up... so you can see how we're barely making ends meet, obviously we have no choice but to raise your rates...:(

Then out of the other corner they'd be telling the agents "It's been another great year! We're doing better than ever, and you should keep selling our plans. We've put together an awesome trip this year for all you agents, so get out there and sell-sell-sell!"

I'm with you on capitalism, beats the hell out of socialism for sure. But the bigwigs in insurance make me want to puke.

Zio,
I work at a large non-profit insurance company as a pharmacy technician in the pharmacy benefits dept. Another reason ins co don't cover every single medication out there is the premiums would also go up every year to cover the cost so keeping cost down for prescriptions also helps with premiums which are drastically going up every year! A lot of companies just can't affort to cover their employee's any longer let alone their families too. We print in our member handbooks that certain drugs require "prior authorization" for coverage. We have a list called "prior authorization list" so people aren't shocked when they get an RX and it's not covered right away. We do review case by case usually in 24-48 hours after we recieve it. we only can recieve any requests from the prescriber, not the pharmacist. And keep in mind that a lot of drug companies come out with something new right when a patent expires! "new and improved long acting, just once a day" etc. Some of these new formulations work just as good as the original!! Ridiculous! I just wanted to throw my 2 cents in from experience. :)