So for the last few years, my medical expenses have been fairly consistent. I absolutely need prescription coverage since the rack rate for them is absolutely ludicrous, but the doctor that prescribes them I see only 4 times a year for only a few minutes to make sure the medications are still working out. She doesn’t take any insurance, but she’s a whole lot better than the other specialists in the field I’ve seen. Even if I get the PPO with the lowest deductible, the out-of-network deductible for 2018 will be more than I would be charged by her all year and I have no plan to see other out-of-network doctors, so I might as well say it’s not covered at all and look at less expensive plans where out-of-network coverage is never covered - HMOs.
But if I have an HMO plan, will the prescriptions written by this out-of-network doctor, when taken to an in-network pharmacy, be covered? I can see arguments both ways, and nothing I see on the internet says anything specifically. They pretty much assume that the main cost of seeing doctors is the treatment the doctor provides, but that’s not the case at all for me - the cost of the prescriptions at the rack rate is much much higher than what the doctor charges me for “treatment”. I have had two sources give me different opinions, but I wouldn’t trust either of them.
I could call Blue Cross and ask one of the health insurance agents, but it takes forever to talk to someone, and usually the first person you talk to can’t help you and you get put on hold for another half hour for someone who actually knows something about what you’re calling about. Another issue I had with the health insurance sign-up process this year I talked to 4 people over 3 hours or so and only the last one even was possible to take steps in the right direction of resolving the issue, and they’ll still need to call me back later. I was originally going to just go with the same plan as last year, but all the time on hold made me actually think about the alternatives.
I am not an expert. This is how I’ve seen this play out.
The HMO does not care who wrote the prescription. They do care about the particular drug. They will refuse to pay for a particular drug or sometimes a class of drugs. I guess it is possible that they could dispute your need for a particular drug and make you see an in network provider.
The list of drugs covered is sometimes called a formulary. Googling BlueCross formulary I come across lists depending on your particular plan. Picking Coumadin, a brand name drug that many plans used to bitch about, I see that it is covered by some of those plans.
That’s all I care about. For all the drugs I take, I get them as generics. I’ve already gone over the list and verified they are all tier 1 (lowest) co-pays for all plans.
As a pharmacist, the only time I see rejects because of the doctor is in Medicaid claims. I’ve never seen a doctor reject in a commercial claim. So with most plans you should be ok. Now, if you’re looking at an in-house HMO like Kaiser who has their own doctors and pharmacy, your mileage may differ.
Hirka T’Bawa, PharmD.
This experience is more than 20!years old, and not totally on point. But I had an HMO refuse to cover a prescription for prophylactic antibiotics by my dentist, even though it was for a medical reason (at the time, the thinking was that people with heart murmurs, no matter how minor and asymptomatic, should have antibiotics before dental cleanings). I ended up just paying out of pocket because it was cheaper than the copay for another doctor visit.
Can’t you get your primary care physician in the HMO to review them and write the scrip? You can always take a prescription to the HMO pharmacy and see what they say.
Contrary to another posters experience, my HMO most definitely care who writes the superscription. If I request a refill at my primary location, I have to pay almost $200 for one drug. But if I take it to the main campus (where the prescribing doctor is located) it drops to $9.
Dennis
I ended up calling Blue Cross and again had to talk to a few people to get someone who could answer my question. They said their HMO (Blue Care Network) does not cover prescriptions written by doctors outside the HMO. It probably depends on the insurer, which is why my answers have been going both directions.
That almost sounds illegal. What if the prescription was written by an emergency room physician on a Friday night? Antibiotics for your stab wound?
I wouldn’t bet my own money, but I think it took awhile to get the answer because that isn’t strictly the right answer. Just my WAG.
Once again, not an expert. Googling around, I don’t see this as a thing. Even Blue Care Network FAQs don’t address this. What they do address is drugs outside of their formulary.
mixdenny says he has come across it though…