Health Insurance and the Formulary
Health insurance policies usually cover prescription drugs on their formularies, which include “both generic and brand name” drugs (Bihari and Norris 2018). For some drugs, patients may have out-of-pocket payments in the form of either copayments or coinsurance (Bihari and Norris 2018). Patients should check to see whether their insurance plans cover their prescriptions, taking into account the amount of medications they take, their “current medications or reasonable alternatives,” and ability to ask for the inclusion of “medically necessary” medications to the formulary (“Prescription Coverage: What Is a Drug Formulary?” 2016). In addition to coverage levels, people have to fulfill conditions to get certain prescription drugs. They may be able to get coverage for drugs not on the formulary through the exceptions process.
Before insurance companies provide coverage for certain drugs, patients may have to meet certain requirements. For instance, health insurance companies may require prior authorization forms from the doctor for certain medications, some of which “may have a safety issue, have a high potential for inappropriate use, or have lower-priced alternatives on the formulary” (Bihari and Norris 2018; “Prescription Coverage: What Is a Drug Formulary?” 2016). Then, companies could provide coverage for these medications if they are “medically necessary” for the patient (“Prescription Coverage: What Is a Drug Formulary?” 2016). Regarding quality care dosing rules, health insurance companies must confirm “that the quantity and dosage [of the prescription medications] is consistent with the recommendations of the FDA” (Bihari and Norris 2018). In step therapy, patients would have to use a cheaper drug for their “health condition before using another medication for that condition” (Bihari and Norris 2018).
For drugs not on the formulary, patients could use the exceptions process to receive some coverage for them, but the process could differ in every policy (“Getting prescription medications”). Though, doctors typically must show that the recommended drug treats the patient’s conditions better than the formulary’s drugs, the formulary’s drugs may induce “side effects that may be harmful to [the patient],” and “That the allowed dosage hasn’t worked for [his or her] condition, or… [the drug] likely won’t work for [the patient] based on [his or her] physical or mental makeup” (“Getting prescription medications”). During the exception process, patients could use the prescription (“Getting prescription medications”). If the company approves it for coverage, the patient is still responsible for copayments and “[any] amount [he or she pays] for the drug will generally count toward [his or her] deductible and/or maximum out-of-pocket limits” (“Getting prescription medications”). If the company rejects it for coverage, patients could “appeal the decision and have it reviewed by an independent third party” (“Getting prescription medications”).
Formularies may provide coverage for certain prescription drugs patients need if the doctors and patients follow the health insurance companies’ conditions. Particularly, the exceptions process show that patients are not restricted to their policies’ formularies.