Why Isn't My Drug Covered by my Insurance Company?

Over recent weeks, several times I have prescribed medications for patient that they could not afford.

Insurance plans do not cover every benefit. With respect to drug coverage, each insurance plans has a formulary - a listing of drugs that are covered. As patients have learned well, covered medicines are categorized into different tiers, which determines to what extent the medication will be covered The lower the tier number, the more money that the patient will have to surrender. Some drugs are simply not on the formulary and can have eye-popping costs which might approach a patient’s monthly mortgage payment.

Distraught woman hoping for a win so she can afford her colitis medicine.

The two medicines that I had prescribed which were then stiff-armed for coverage were for colitis. I had the patients research the costs and they and I were shocked by their findings. At first, I thought they may have misplaced the decimal point, but the more expensive of the two was priced at $2,000 for a prescription.

Sparing my readers the medical details, both of these medicines are considered mainstream colitis medicines. They have been approved for this use by the Food and Drug Administration (FDA) years ago. And importantly, neither has an equivalent alternative. For example, if I prescribe a heartburn medicine and discover it is ‘off formulary’, there will (hopefully) be equivalent alternatives available for the patient. Not so with my recent colitis patients.

How would it feel to be sick, have medical insurance and not be able to afford the medicine that would make you well?

For luckier colitis patients whose medical plans cover these drugs, the costs are extremely low. What this means to me is that the system is unfair and broken.

Leaving aside contracts and formularies and the overall labyrinthine insurance companies, shouldn’t a patient who has insurance and who’s played by all the rules be covered for an FDA approved medicine that his doctor recommends?

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