Prescription drug plans: newbie question

Factual Questions
1

I’m a bit new to American-style prescription drug companies and I have a question.
1/ Some health care organizations (like State Medicaid) seem to have a drug formulary that lists all the drugs they will cover. Some drugs on the formulary are checked off as requiring Prior Authorization – that is, your doctor has to complete a special form explaining why the drug is needed.

2/ Other health care organizations (like BCBS and Atena) seem to have different plans (1-tier, 2-tier, 3-tier) for their customers where they offer all drugs. Depending on your plan, you have to pay some, all, or none or the drug cost for a prescription. They don’t, however, seem to have Prior Authorization procedures. That is, a doctor can prescribe anything. The only barrier is whether you want to pay if it’s not covered on your plan.

Is that about right? Or am I totally off? If a company offers tiered coverage, does that pretty much always mean it doesn’t have list of Prior Authorization drugs?

2

Poor jdl…welcome to the Hell that is U.S. healthcare coverage.

You seem to have the concepts down, but the specifics of coverage are up to each individual plan. So for example, Aetna can have a traditional indemnity plan which covers anything your doctor wants to prescribe, a PPO which covers some thiings but not others, and an HMO which covers even less things. Then, just to make life more interesting, some items (most commonly birth control pills, but sometimes other maintenance drugs, i.e. things where you can predict the need for them, like insulin) are covered sometimes, but perhaps only if they are filled through the plan’s chosen mail-order pharmacy.

Again, keep in mind that your doctor can prescribe anything, but that doesn’t mean the insurance company will pay for it. Right now, for example, my plan will only cover certain antibiotics…the fun part is that when I get a sinus infection, I know from experience that none of the formulary antibiotics will kill it, but I am required either to try one or more of those first before they will cover one of the ones that works, or have my doctor write them a letter and then let them take their time deciding whether they’ll make an exception for me. That’s just what I feel like doing when I feel like my head is going to explode, but the only alternative seems to be paying more than $100 out of pocket for the new ones that are still under patent, because I know they’ll work the first time around…

Good luck, and make friends with your primary doctor and the insurance co.'s benefits explanation people!

3

Thanks for the info. Some more questions: What the is difference between:

  • Non-covered medications
  • Non-preferred medications
  • Medications requiring prior authorization

Thanks!

4

I’m guessing (although you should read your policy info booklet):

-Non-covered medications: things they won’t pay for under any circumstances

  • Non-preferred medications: things they discourage you from using by enforcing a higher co-pay or otherwise lower level of benefits

  • Meidiations requiring prior authorization: exactly what it says, i.e. you need to get the insurance company’s permission first (why, God only knows).