Is It True?
- Thread starter Monti_Ray
- Start date
- 2,130
Probably not............
Depends on how you want to look at it. In a way, it is true. Some plans may have a step program and make patients start over with their pharmaceutical regimen. So in that way, yes your new plan may deny your drug. It may be a simpler explanation that your drug isn't covered by the formulary. It isn't that the ailment isn't covered, it is simply your new plan doesn't cover that drug and you will have to change drugs.
To plainly state that Obamacare won't cover your pre-existing condition is false; however you may have to jump through new hoops and start over due to losing a doctor or a prescription which ulitmately will feel as though Obamacare won't cover your pre-existing.
To plainly state that Obamacare won't cover your pre-existing condition is false; however you may have to jump through new hoops and start over due to losing a doctor or a prescription which ulitmately will feel as though Obamacare won't cover your pre-existing.
Step-therapy and Prior Auth is not denying coverage on prescriptions. Its proving that you really need the most expensive drug in that class. Or that you are taking the drug for an FDA approved reason. I'm not buying it. Plus, that happens every time you change carriers, so what does that have to do with ACA?
Let me start by saying, I was a pharmacy tech through high school and college. I worked for a PBM for 10 years. Then went on to a major carrier before jumping off the cliff to start my agency 12 years ago.
And I was replying to the original post, not you, timsip, but since you graciously challenged me, here you go.
PBM's typically do not require patients that are on a prior auth or step drug to repeat any processes. If you are on Nexium (a common step drug) and can prove you have already met the step requirements, they don't make you go through the process again. Your doc calls says what you have already tried and its approved. Its a huge PIA, but anytime you switch carriers its the same issue. As agents, I believe part of job is educating our clients on how to do this as quickly and effectively as possible.
A formulary does NOT determine coverage. It determines cost. It determines what level the drug is covered. Step therapy, prior authorization and quantity limits are not part of the formulary process. A drug can be on the preferred formulary, but still require step therapy or prior auth or have quantity limits. Those are different items.
Example: Imitrex (oral) is always covered. Some carriers will have it preferred, some won't. But you can only get 6 pills. And that's because the FDA has stated that 6 pills per month is the maximum safe amount. And if you have more than 6 migraines per month, the FDA thinks you should be diagnosed with "cluster migraines". And Imitrex is not approved for cluster migraines.
A drug can be not on the formulary and still covered. There has always been a list of drugs that are not covered. And whenever you switch carriers, that has been an issue. This isn't an ACA issue. Its just an issue. That's been around for 25 years, since PBM's became a player.
ACA hasn't really said any drug class has to be covered. Except birth control.
But all the policies have Viagra coverage
And now, its Saturday night and time for a margarita!
And I was replying to the original post, not you, timsip, but since you graciously challenged me, here you go.
PBM's typically do not require patients that are on a prior auth or step drug to repeat any processes. If you are on Nexium (a common step drug) and can prove you have already met the step requirements, they don't make you go through the process again. Your doc calls says what you have already tried and its approved. Its a huge PIA, but anytime you switch carriers its the same issue. As agents, I believe part of job is educating our clients on how to do this as quickly and effectively as possible.
A formulary does NOT determine coverage. It determines cost. It determines what level the drug is covered. Step therapy, prior authorization and quantity limits are not part of the formulary process. A drug can be on the preferred formulary, but still require step therapy or prior auth or have quantity limits. Those are different items.
Example: Imitrex (oral) is always covered. Some carriers will have it preferred, some won't. But you can only get 6 pills. And that's because the FDA has stated that 6 pills per month is the maximum safe amount. And if you have more than 6 migraines per month, the FDA thinks you should be diagnosed with "cluster migraines". And Imitrex is not approved for cluster migraines.
A drug can be not on the formulary and still covered. There has always been a list of drugs that are not covered. And whenever you switch carriers, that has been an issue. This isn't an ACA issue. Its just an issue. That's been around for 25 years, since PBM's became a player.
ACA hasn't really said any drug class has to be covered. Except birth control.
But all the policies have Viagra coverage
And now, its Saturday night and time for a margarita!
This isn't an ACA issue. Its just an issue. That's been around for 25 years, since PBM's became a player.
ACA hasn't really said any drug class has to be covered. Except birth control.
But all the policies have Viagra coverage
And now, its Saturday night and time for a margarita!
And again, this was my point from the beginning. Step therapy isn't exclusive to ACA, but if you look at the source of the article, you will see that it is being spun as such.
Sure you can buy any drug on the market that is prescribed to you, but tell that to those that are receiving huge subsidies and CSR credits. The drugs not on the formulary are still not available to those patients regardless of the level of coverage. The point that the news article is trying to make in a grossly political way is that if you are currently on a specialty drug that is covered by your current insurer, when you switch to an ACA compliant plan, you may not be able to get that drug covered at least in the beginning.
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How can insurance companies comply with Obamacare, and cover all pre ex, but then say NO we aren't going to cover a drug that is medically necessary to treat the pre existing medical condition? Makes no sense to me. Isn't pre authorization under Obamacare or Step therapy really a NON issue, esp. with HSA style plans? Once the HSA deductible is met, its covered....what gives?!
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At the risk of skidding into the off topic ditch here, I am working with someone who had questions about an on exchange plan formulary. I need to review the possibility of step therapy, appeals, etc. in under 65 plans. Thanks, kgmom17 for info.
Back to client: No coverage for Adderall brand of drug for ADHD on the plan client likes, or for a generic. A different carrier covers the generic. I guess I am old enough that finding out the generic for Adderall is amphetamine/dextroamphetamine made me gasp a little. Straight up speed. Whoa.
I know, there's research that these drugs don't have the normal effects for true ADD/ADHD people. Slows them down. But still....I get visions of Breaking Bad....
Back to client: No coverage for Adderall brand of drug for ADHD on the plan client likes, or for a generic. A different carrier covers the generic. I guess I am old enough that finding out the generic for Adderall is amphetamine/dextroamphetamine made me gasp a little. Straight up speed. Whoa.
I know, there's research that these drugs don't have the normal effects for true ADD/ADHD people. Slows them down. But still....I get visions of Breaking Bad....
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I'll assume that Rx under ACA will be handled the same way as under Medicare, that there needs to be at least one medication in the formulary for each treatment class.
A patient who is using a medication that isn't in the formulary is automatically given a 30 day supply in these situations and can then file an appeal to continue the med, these are granted more often than not.
The media never takes the time to thoroughly research anything and provide a balanced perspective, those days of responsible journalism are long gone.
