Unfortunately, during the course of your relationship with your physician, you may find that, despite your doctor’s careful efforts to find the right medicines and doses to help you best manage your health, your insurance company may deny coverage or reimbursement for certain medications.
As part of your insurance policy, these companies are allowed to restrict how and what doctors prescribe to their patients.
They may deny medications under various rules of formulary, pre-requisites or TIER programs. For example, they may require the doctor to try their preferred (formulary) drug before the one doctor believes is best for you. Insurance companies cover generics for lower prices, but may or may not cover brand names or even medicines which you need but do not have generics available. This is ESPECIALLY common with psychiatric medications. Despite their assurances to you that the medicine you need is covered, they can change their formulary in the middle of your policy contract. You would then be required to pay for the entirety of the medication or simply not take it, despite your best efforts to improve your health with your doctors help.
Your insurer will tell you that your doctor must get a preauthorization (PA). In our experience, this involves your doctor directly spending 30+ minutes on the phone for each prescription clearing bureaucratic hurdles. This process tends to complicate your access to medication by making obtaining authorization a tedious, time consuming and expensive process for the patient and physician. Frequently, despite your doctor’s time spent away from patients while on the phone, a computer or call-center worker denies your medication.
Unfortunately, this process prevents us from seeing and helping our patients. So we made a difficult decision not to participate in this frustrating and often futile exercise. We refuse to let our prescribing behavior and our desire to offer the best possible care to our patients be compromised by insurance bureaucracy. We want you to have the medicines we think are right for you, but the insurance company may not let that happen.
However, we recognize that cost and choice are important to you, so as you begin treatment, we will prescribe generics only. If we feel that the best choice for your health is a brand name medicine for which a generic is unavailable or a medicine that is not covered by your policy with or without pre-authorization, we will need your help. Please contact your insurance company – your involvement will not only benefit you by gaining you access to coverage for the medications you need, but also benefit your fellow patients by helping change these onerous insurance practices. You can also call the State Board of Insurance or the State Board of Pharmacy to advocate on your behalf. Unfortunately, many insurers reside outside of the Lone Star State and Texas law may not apply to them.
We will do our best to accommodate your needs, from both a health and financial perspective. We encourage you to be proactive in both these regards and look forward to our partnership in improving your health.
