<p>GP,</p>
<p>I understand your frustration, but all is not lost. You can have your physician advocate for you. If there is strong argument that a particular drug has to be used, chances are the insurance will approve it through exception process.</p>
<p>Here’s a very recent news article that has a good summary of prescription drug benefits under ACA and formulary issues:
[Things</a> you need to know about the Affordable Care Act and prescription drugs ? but probably don?t - The Washington Post](<a href=“http://www.washingtonpost.com/national/health-science/things-you-need-to-know-about-the-affordable-care-act-and-prescription-drugs--but-probably-dont/2013/12/09/c00054c4-5eba-11e3-95c2-13623eb2b0e1_story.html]Things”>http://www.washingtonpost.com/national/health-science/things-you-need-to-know-about-the-affordable-care-act-and-prescription-drugs--but-probably-dont/2013/12/09/c00054c4-5eba-11e3-95c2-13623eb2b0e1_story.html)</p>
<p>Yes, but one of the tiers is non-formulary drugs. At least pre-2014</p>
<p>Are we talking about a case where it’s the only drug? Or something discretionary- like, you don’t want the generic or alternative? How much of a fight does this have to be, to take care of the condition?</p>
<p>How much of a fight does this have to be, to take care of the condition? </p>
<p>Good question.</p>
<p>I have no clue how the drug thing works or how it worked in the past. I just think it’s probably something to be aware of when picking a plan if it’s an issue in your case. </p>
<p>FYI, there are plans on our state which cover out of state dependents. So that is good news in NC</p>
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</p>
<p>I think every condition will have a drug. It might not be an effective drug from the physician’s point of view, but there will be a drug on the preferred list.</p>
<p>The frustration is that it is very difficult to know if the formulary is sufficient if you are given a list of drugs in the formulary unless you can compare it to list from the 2013 formulary. A very tedious job. It would be nice if the insurance companies and the exchanges volunteered this information, rather than making us do all the legwork.</p>
<p>I have both lists. :)</p>
<p>LF, if there is only one drug to treat a condition, and it is the accepted treatment - then the insurance has to cover it. There can be variations as related to co-pay or co-insurance – but the insurance company can’t deny a patient needed treatment. The problems might arise if there are multiple drugs to choose from, but some are more expensive than others; or if the use of the particular drug for the particular condition is experimental or unorthodox. And expensive: I think it’s safe to assume that the insurance companies are going to be quite happy to pay for low-cost generics.</p>
<p>“effective drug from the physician’s point of view”</p>
<p>Not very comforting</p>
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<p>For my family it was a phone call from a physician.</p>
<p>I can’t see why comparing the 2013 formulary to the 2014 formulary would tell you if the 2014 formulary was adequate. Maybe there were some drugs that shouldn’t have been on the 2013 list. Maybe the 2104 list has added just the drugs you would wish for if you knew what to wish for.</p>
<p>I take a fairly common brand name drug that is not on the Anthem formulary. It does have a generic equivalent but my doctor thinks this is a better drug.</p>
<p>GP,</p>
<p>use exception process.</p>
<p>I will try. Don’t have to deal with this for a couple more months.</p>
<p>When thinking about whether an insurance company should cover whatever the doctor asks for, consider Avastin and Lucentis for eye problems. </p>
<p>[An</a> effective eye drug is available for $50. But many doctors choose a $2,000 alternative. - The Washington Post](<a href=“http://www.washingtonpost.com/business/economy/an-effective-eye-drug-is-available-for-50-but-many-doctors-choose-a-2000-alternative/2013/12/07/1a96628e-55e7-11e3-8304-caf30787c0a9_story.html]An”>http://www.washingtonpost.com/business/economy/an-effective-eye-drug-is-available-for-50-but-many-doctors-choose-a-2000-alternative/2013/12/07/1a96628e-55e7-11e3-8304-caf30787c0a9_story.html)</p>
<p>Should your insurance company cover $2000 Lucentis when $50 Avastin is just as good?</p>
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</p>
<p>I would start working on it sooner rather than later (before you need to get a refill).</p>
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<p>Why? What does the brand name drug offer that the generic doesn’t?</p>
<p>Because of potential side effects</p>