How Could It Be Health Insurance May Refuse A Rx Your Doctor Prescribes To Your Patient?

[burt]

I'd some blood tests completed lately, the doctor referred to as me to inform me that she was receiving me on a specific medicine due to a difficulty she present in my positive aspects. Right away I was wanted by them onto it. The pharmacy told me that my insurance coverage refused it and need her to spot me on an additional thing, when I went 24 hours later to decide on it up. Nowadays, I've an awsome physician, would not she recognize much better then your insurance business what is ideal for me personally?Do the insurance coverage organizations have use of all-out health-related files?Iam slightly lost.

[Berwynne]

They don't care about your well-being or health. They just want the cheapest possible treatment. Your doctor wants the most effective treatment and there is the whole difference. Your doctor is working for you, the insurance company for it's shareholders

[Waerheall]

I take calls for a pharmacy benefits manager. I deal with this day in and out. It definitely stinks but unfortunately just because your doctor prescribes it does not mean it will be covered. It is very true what everyone says on here. There is no profit in covering an expensive medicine with low or no cost to the member.   bmac87 23 months ago

[Nechemya]

It's called a "formulary" and you should check yours. Your doctor prescribed the medication that she felt you should take. Your insurance company doesn't cover it, so in order to save you some money they want to see if your doctor could prescribe something different. It's up to you(and your doctor) to decide if another medication would be as good OR if you should pay out of pocket for the original prescribed medication. It may be a matter of the insurance company only covering a generic prescription vs. the brand-name one your doctor prescribed. Or they may just not cover that type of medication(I know this isn't your situation, but one example I can think of is that some insurance companies don't cover birth control or only cover certain types). Insurance companies don't have access to all our medical records, but when you want something covered by insurance(such as a medication or a specific medical procedure) they're able to see what you want covered and if it's in your policy to be covered. If they have questions regarding a claim you/your doctor/your pharmacist have submitted, they can request medical records and pertinent information to determine coverage. You should call your doctor, tell her the circumstances, and get her advice as to what you should do.

[Hegarty]

If it's not on their list of covered drugs they just flat out won't cover it.  The doctor told me it may not be covered.  Up until that point I thought whatever the doctor prescribed would be covered.  Sometimes if you make a fuss about it they may cover your prescription especially if your life and health depend on it.   Here's a good website on your privacy rights:   http://www.privacyrights.org/fs/fs8-med.htm

[Valiant]

But your HMO wants you on the cheapest medicine, probably generic. The HMO wants to save money.Insurance companies do have access to all your medical records, that doesn't mean they are requesting a different medicine because it's better for your condition.

[Ranger]

Your insurance company has one idea - save money! They don't care about your well-being or health. They just want the cheapest possible treatment. Your doctor wants the most effective treatment and there is the whole difference. Your doctor is working for you, the insurance company for it's shareholders edfoug 82 months ago Please sign in to give a compliment. Please verify your account to give a compliment. Please sign in to send a message. Please verify your account to send a message.

[Anwell]

I have encountered this as well, and I can see it from a variety of perpectives.   It generally boils down to the fact that many medications have an alternative that is deemed to be as safe and effective in treating the same condition.  Often it?s a generic, or sometimes it?s a different drug in the same family.  On occassion it?s a different class of drug altogether which tests indicate has the same net impact.    Insurance essentially is a business...it?s about keeping revenues as high as possible and keeping costs as low as possible.  Any shrewd business person is going to know that you?re not going to keep your costs low by making bad decisions that adversely affect the health of their subscribers, because a) they risk costly litigation and b) they have a vested interest in keeping their subscribers healthy, because healthier subscribers have fewer claims, but they get the same amount from you whether you?re healthy or not.  This is the whole reason the business model works.  Essentially, a lot of people don?t think of insurance companies as a "business", but that?s exactly what they are.  If you personally wanted to start a health insurance company, essentially the only barriers to entering that field would be the same barriers to entering any field.  There are certainly many regulations, but if you had millions to invest, it would be a great investment.    Insurance essentially works like this...they get a whole bunch of people who are members of their plan.  Then they go to the various medical providers and say hey, we have x million subscribers.  If you want our subscribers to be able to come to your clinic if they want to, you?re going to want to accept our insurance plan.  Our insurance plan won?t pay you what you?re billing people, but we will pay you these amounts.  And basically they have a chart that says for an office visit, we pay this much, for an appendectomy we pay this much, etc.  So, basically, the doctor bills whatever the doctor bills, and the insurance company only pays whatever they agreed to pay, and disallows the rest.  It?s just like buying in bulk...instead of one person going in for a physical, they can say we?ll buy 30% of your physicals, but you need to cut us a great deal.  Then the insurance companies work with employers on the other side to get subscribers.  They look at how big your organization is and use that to decide what rate structure is going to be most attractive to the employer while still providing the most revenue for the health insurer.  So then with a larger company, maybe they?re charging $500 a month per person, and they know that they?re getting a lot of 20 somethings who almost never go to the doctor, and they?re also getting the people who are chronically ill, so essentially it averages out, and no matter how much the heaviest users cost them, sure they?d be taking a loss if they sold that person an individual policy for that price, but they make so much on the people who have light medical needs that it doesn?t matter.  Bigger companies like to have something where they can standardize their costs, so it saves them in administration to do it this way.  They can then pass whatever percentage they want to along to the people who take the insurance in the form of a monthly deduction from everyone?s paycheck.  Still, the employer pays a lot for these benefits, but it?s a compensation cost and it won?t be a problem for them if an employee falls ill.  For a smaller employer, often the rates are tiered, so that the 25-35 year olds cost the company far less than the 60-65 year olds, they adjust these rates based on the idea that in order to ensure profits based on the average medical costs for a person age x I have to charge this amount, and age y I have to charge that amount.  The employer still generally bears a lot of this cost, but the younger workers pay less in premiums.  So, by controlling things at this level, they ensure that revenues will outpace costs.    But they still have to keep costs under control, because even though they negotiate rates with medical providers each year, they also have to pay for medications, and those costs are far less easy to reign in.  They have some leeway here, but it?s not like the consumer has the choice...they can go to a variety of pharmacies, some of which will have higher markups than others, but most of the cost of a medication is from the drug companies that make them.  The drug companies essentially spend many years and millions of dollars working on each drug they put out.  By the time it hits the market, it may not cost much to produce, but it cost a lot to create, so they have to recoup those costs.  Because a drug only gets a patent for a certain amount of time, the drug companies have the incentive to charge as much as they can get for it during the first I believe 11 years it?s on the market.  Once it has been on the market for this period of time, they no longer can exclusively produce it, and the formula becomes public knowledge.  Any company that makes generics can just get the ingredients and mix it up, and that?s why places like Wal-Mart can sell the generics for $4 for a 30 day supply.  Even after a generic hits the market however, the name brand remains expensive as many people are already on the product and many prefer the name brand because they feel there is a difference.  Really though, for the most part the only differences are in the additives.  It has however been reported by some patients and doctors that certain generic drugs, even though they theoreticially should be as effective, simply are not.  This could be due to a certain suggestibility of some patients, or possibly an interaction with an additive, or a difference in the production process...no one really knows, but for the vast majority of medications, generics are for all intents and purposes the same drug.  So, if the insurance company knows that it?s going to cost $150 a month to keep a patient on drug A, but only $10 a month to keep them on a generic version of drug A, the doctor may prescribe drug A, but when the patient goes to fill it at the pharmacy, the insurance company will say, no, you need to try the generic instead.   At times, and I?m not saying your Dr. is guilty of this, but her or she is certainly subjected to this, drug companies spend a LOT of money on getting doctors to prescribe their medications.  They have huge marketing budgets and they?ll have these very attractive, sharp dressed reps come in to each clinic at a certain time each week, to present information, along with goodies, such as free samples of the medications for their patients to try, possibly a nice lunch or bagels for the staff, and of course promotional merchandise.  It?s an outright attempt to buy influence...just like in politics.  Even if the doctor is of high integrity and refuses to be bought, he or she will understand that each of these drugs does do something and would help certain patients.  When it comes time to prescribe something, if there?s a generic equivalent, they certainly aren?t going to be writing the prescription with a pen provided by the company that makes the generic.  There?s name recognition for the name brand...and there?s also the fact that medicine advances quickly.  Every doctor can not keep up with every new drug on the market and its generic equivalents...often they can look it up, but time is money and that takes time.  The doctor has the incentive for many reasons to simply write the prescription for the drug whose name most easily comes to the front of the brain...they figure if the drug company wants to suggest a generic, so be it.    Now sometimes there are other drugs in the same family, they?re derived in the same way, but they are not exactly the same drug.  If tests have shown them to be effective at the same thing, even though they may not be as interchangeable as generics, often one may be far cheaper than the other.  The insurance is going to want to push the cheaper option in cases where it will work best.  Problem is, the insurance companies can?t tell which one the patient will respond best to, and in most cases, neither can the doctor.  Often, the only way to know if the cheaper alternative will work is to try it.  Doctors don?t know the policies of each insurance company as it relates to each drug and it?s equivalents, so they can?t really prescribe anything in a one size fits all way, so again, they?re going to default to the industry leader, the one that gave them that notepad on their desk, the one whose reps met personally with that doctor just last week.    And finally, with any condition, there are generally multiple ways to treat it.  At times a drug may be new, having no generics, and it may not lend itself to having other drugs in the same family that also treat the same condition.  But perhaps there are more tried and true ways of treating this condition...now none of these ways might be AS effective as this new pill, but they?re certainly a LOT cheaper.  From both a cost standpoint, and the viewpoint of minimizing liability, health insurers often don?t want to pay for these drugs, because at times, as we?ve seen with a number of newly introduced drugs on the market, there are really bad side effects which aren?t known until a whole bunch of people start taking it for a couple years and some of them start to die.  Most insurance companies would rather be very conservative before they OK payment for anything for this reason, and it?s just an unintended consequence for them that there are other cheaper alternatives.    So, in order to make sure that they can make a case for these things, health insurers adopt what is called a forumlary, which is essentially a list of all the medications they will pay for.  There is generally a second tier to the forumulary where there are drugs which have been shown to have alternatives which are cheaper and supposedly as safe and effective(those alternatives would be on the first tier of the formulary...the drugs they cover no questions asked).  Anything on this list, they will bounce back on first attempt and say, we recommend this option instead.  The doctor then has to either say, yes, that?s fine in which case the patient gets the generic, or they have to have a reason they want the patient on the name brand.  The doctor will put through what is called a prior authorization which says they are specifically stating that for this patient, they want to use this drug for these reasons.  Often insurers will require(unless doing so would put a patient?s health at great risk) that a patient/subscriber try one or two alternatives first, and then if they try something and it doesn?t work, but the doctor still thinks the name brand will succeed where the alternative failed, the patient then has the prior authorization to be covered for that medication.  However, they are not going to get certain drugs approved at all if the insurance company thinks it?s too big of a risk as the medicine is not yet proven effective.    So, no...the insurance company doesn?t have access to all your medical records...they have access to all your claims.  They?ll know by virtue of the tests you?ve taken and the drugs you?ve been prescribed if you have a health concern, but by denying you to get a drug prescribed urgently by your doctor, they are not trying to second guess the doctor.  They have simply identified, long before you ever had a prescription, that in their estimation, they will save a lot of money without endangering the well being of their subscribers if they suggest a certain alternative or alternatives whenever a claim is presented for a particular drug.  If the results of your blood test indicate that the drug she originally prescribed is really the one best way to treat your condition, then she will go through the proper channels to get them to back down.  If however the doctor thinks there?s a very good chance the medication the insurance company has recommended would do the trick, she?ll recommend the alternative, the prescription will get changed and you?ll go on the alternative.    Basically, it?s all predetermined, the insurance company is not making any attempt to diagnose anything.  What they?re trying to do is run a profitable business, and like any other business, they have competition, in their case, the other insurance companies that operate in the same states.  They know what the "competition" charges for coverage, so they need to be able to offer coverage that is competitive...if they charge a lot more than any other insurer, even if the benefits are far better in terms of something like prescription drugs, they know that employers and individuals who buy their coverage just aren?t going to be able to justify spending a lot more money.  This is why often a big company will announce that it?s going to a different insurance company as of such and such a date...because 3 months before the current year policy was up, they got a renewal quote and the price went up by 15%.  Well, maybe everyone?s price for that package went up considerably, but now they realize that by making the employees share a bit more of the cost via higher copays and annual out of pocket expenses, they can switch to another plan that doesn?t cost them much more than they were paying.  And whereas company A had the best rates for people who want the deluxe plan, company B seems to have the best rates for companies that want the standard plan.  So, competition gets very fierce here, and they know that if they don?t keep costs down wherever possible, they may have to start looking at a 30% rate increase instead of a 15% rate increase, and the more they increase the rates, the more likely the subscribers are to shop around, and they don?t want that.  So whatever one does, by and large the others will do, and the biggest way for insurers to keep costs low is to control them.    They do this via the lists...the one list that says for any given reason a person would need to see the doctor, this is what we will pay.  The other list is for every single medication that can be used to treat any condition, what alternatives are there and what do the various alternatives cost, and in what percentage of patients are they as effective as the most expensive method.  If they find that there is an alternative to a treatment for something that is very severe but that this alternative only works about half the time, and that if it is prescribed and doesn?t end up working, they could be sued for having suggested it as an alternative then they figure it?s best to just cover this drug even though it?s a lot more expensive.  But like any business decision, each one of these drugs and their position on the formulary, they?ve undoubtedly done a cost/benefit analysis.  They?re going to determine what is the overall least costly way to go, just like any business.  When you get right down to it, in the real world, that can come off as very harsh.  A good example of this is in a different industry...the auto industry.    If you?ve ever seen the movie Fight Club, Ed Norton plays a character who does cost/benefit analyses for a large automaker.  I can?t remember exactly how he put it in the movie, but the gyst is that essentially, let?s say they find out about a flaw in some of their vehicles that makes the gas tank explode with no warning from time to time.  His job was to figure out what the total cost would be to the automaker would be per explosion in terms of legal costs, damages, loss of business/PR etc.  Then they determine how much would it cost to recall every vehicle which might have this defect.  They then come up with a number of injuries/deaths/explosions that they?d have to experience in order for it to be less costly for them to do the recall.  If they can determine that 500 vehicles would have to explode killing a total of 500 people and injuring 1,000 would likely cost them the same amount as it would to recall all 3 million vehicles sold with this problem, then then look at the other question.  They determine how many vehicles are on the road with this defect and the percentage chance that the explosion will happen, and if they find that they can reasonably expect that only 100 of these vehicles will explode, killing a total of 100 people and injuring 200, to them the consideration is not that we can save 100 lives and 200 injuries...to them its 80% cheaper to let those explosions happen and face the consequences.    So, apply this to the insurance companies...they?re going to look at Drug A, and determine that 25,000 of their subscribers will eventually be prescribed this medication, at an annual cost of $50 million.  They know that there?s another drug that if all 25,000 of these people switched, it would cost them $2 million a  year.  They also know that 10% of people won?t respond to the alternative and will end up back on the more expensive medicine, but still, the annual cost is under $7 million a year, they?ve saved $43 million a year.  Now, they also know that trying this drug could potentially cause a host of problems for the patients, which in turn could lead to higher costs for the health insurer if they now have to pay for another treatment or another drug, or if the patient gets so sick(or even dies), that they will be subject to a lawsuit, then the added costs of doing this might end up being estimated to be $60 million a year, in which case it?s just not worth it for them to suggest the alternative.  But, in the vast majority of cases, it?s not going to kill someone, or even deteriorate their health enough to have any costs associated with this decision, so it?s best to serve 90% of the people on the first try and the additional 10% on the second try because it?s the cheapest overall way to do it.  Even if they determined that this change would result in an additional $20 million in expenses for the patients who were not served on the first try and developed other health concerns because of it, still the total cost of going this way would be far less than the total costs of just allowing the drug.  They want you to think that your health is a concern to them, but the care only inasmuch as maintaining your health will save them money.    Any time you have a drug however that someone is going to prescribe to you and you are going to pick up at a later time and administer, chances are it?s not going to be a matter of life and death.  It may be something that won?t ultimately work, which you might well know in a month isn?t doing the trick, but that one month of not being treated in the best possible way is unlikely to be life threatening in the vast majority of instances where one can be trusted to self administer the drug anyway.  If you?re in the hospital and you need drug X right now to keep your heart pumping, well Drug X has already been approved as a medical treatment where they have agreed to pay a certain amount for it when they get the bill.  So, I?d say in the very vast majority of cases, if the health insurer is saying that they?d rather give you drug B than the drug you were prescribed, what is happening is they have a cheaper alternative, and they have evidence that says that drug B will work in the vast majority of patients as well as drug A.  If there is persuasive evidence that not giving you what was prescribed is dangerous to your health, then the doctor has a way to let the insurance company know that, and most likely they will just back down...they don?t want to be put in a situation where their cost savings is trumping the medical opinion of a doctor...to much potential for liability, particularly if the doctor says that without drug A, patient will die, even if given drug B.  But in most cases, the doctor is then going to have this same evidence, and she is going to say it does appear that this has at least a 90% as good a chance of working as what I prescribed, and if she can also say that even if my patient is in the 10% it?s not going to harm his/her overall health in the long run, then the doctor will have no reason to challenge the health insurer.  But I know that what?s in the medical texts does not always match the doctor?s real life experience(some times the studies are anecdotal at best, and the doctor makes his/her best decisions based on the experiences of his/her patients...they?ll know if 10% of people who?ve tried the alternative really didn?t react well, or if 60% didn?t, more than any study will).   Bottom line, if you trust your doctor as much as you say you do, trust that if she says it?s OK for you to try the alternative, then she thinks there?s certainly a good chance that it could be as good for you, and that at least it won?t hurt you...or at very least many doctors will say it?s all part of playing the game...they know it can?t hurt you in the short term to be treated with the alternate solution, but ultimately it won?t help you, so even if their experience tells them it isn?t going to work, if there?s no harm that could come to you, they figure, let?s play the game, let one or two alternates fail, and then the patient will never have another problem unless they switch insurance companies.  They also know that once you?re on something, there?s a lot of reasons for many drugs not to switch, so they can usually fight off any attempt to make you try a different treatment once you?ve already been on a particular treatment, even if you?ve switched insurers.    Call your doctor, tell her what the insurance company said...she probably already knows, and see if she thinks their alternative is fine or not.  If she says it?s OK, trust her, if she says it?s not OK, you can rest assured that she will do everything she can to get the insurance company to back down.  It?s how the insurance game works!  

[Clem]

I have been denied an Rx.......... If it's not on their list of covered drugs they just flat out won't cover it.  The doctor told me it may not be covered.  Up until that point I thought whatever the doctor prescribed would be covered.  Sometimes if you make a fuss about it they may cover your prescription especially if your life and health depend on it.   Here's a good website on your privacy rights:   http://www.privacyrights.org/fs/fs8-med.htm Sources: internet   AgentOrange's Recommendations The Practical Guide to HIPAA Privacy and Security Compliance Amazon List Price: $99.95 Used from: $47.50 Average Customer Rating: 5.0 out of 5(based on 7 reviews) HIPAA: A Practical Guide to the Privacy and Security of Health Data Amazon List Price: $79.95 Used from: $45.95 Average Customer Rating: 2.0 out of 5(based on 1 reviews) HIPAA 1 Overview Amazon List Price: $49.95 Stedman's Guide to the HIPAA Privacy Rule Amazon List Price: $41.95 Used from: $27.82 AgentOrange 82 months ago Please sign in to give a compliment. Please verify your account to give a compliment. Please sign in to send a message. Please verify your account to send a message.