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 higher 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 gambling 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 company policies, 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?

Comments

Becoming a Part-Time Physician

Next month my schedule will change. I will henceforth be off on Fridays with my work week truncated to Monday through Thursday. I am excited to be enjoying a long weekend every weekend. And while the schedule change is relatively minor, this event does feel like an important career moment for me. It is the first step on a journey that will ultimately lead beyond my professional career. It is this recognition that makes this modest schedule modification more significant than one would think it deserves. As some readers know, my current employed position has been a dream job for me. Prior to this, I was in a small private practice, which I loved, but was much more challenging professionally and personally. My partner and I ran the business. Working nights, weekends and holidays were routine for decades. On an on-call night, if I slept through until morning, I felt as if I had won the lottery. And w...

When Should Doctors Retire?

I am asked with some regularity whether I am aiming to retire in the near term. Years ago, I never received such inquiries. Why now? Might it be because my coiffure and goatee – although finely-manicured – has long entered the gray area? Could it be because many other even younger physicians have given up their stethoscopes for lives of leisure? (Hopefully, my inquiring patients are not suspecting me of professional performance lapses!) Interestingly, a nurse in my office recently approached me and asked me sotto voce that she heard I was retiring. “Interesting,” I remarked. Since I was unaware of this retirement news, I asked her when would be my last day at work. I have no idea where this erroneous rumor originated from. I requested that my nurse-friend contact her flawed intel source and set him or her straight. Retirement might seem tempting to me as I have so many other interests. Indeed, reading and ...

Will Smarter Lawyers End Frivolous Lawsuits?

How do you know if a lawyer is any good? Of course, they've all passed the bar, but now their profession is lowering it. While most of us strive for excellence, and raise our children to value this virtue, prominent legal educators are establishing a new quality intitiative for their profession. Who says that lawyers can't reform themselves? Perhaps, we physicians can follow their bold example and raise the credentials of our pre-medical students. I’ll present the facts. You be the judge. I have written a dozen posts on tort reform on this blog, which always generate spirited and adversarial retorts from attorneys and their supporters. They accuse me and other tort reform advocates of carrying water for insurance companies. They repeatedly point out that I know nothing about the legal system and are unqualified to opine on its flaws. They deride me when I argue that effective tort reform would reduce the practice of defensive medicine, despite the re...

MD Whistleblower

Search This Blog