Home Forums Discussions General Discussion Drug Formularies

Drugs covered or not covered by insurances are so confusing. We have mostly medicaid patients and even though they're spread out over 5 managed care plans; thankfully, they all have to use the "texas medicaid formulary," which is published on the web. But some drugs are covered for only the brand name, and we have to hand write "brand medically necessary" on the script. Some generic drugs are covered but it's a store generic version, so you can only get it at Walgreens. If we send it to CVS they just fax back asing for PA. (But the formulary doesn't specify the store name of course, just different NDC numbers.)

One time an Rx for a private insurance pt was rejected for not preferred. I had no idea how to look up an equivalent that would be covered. The doctor just picked another one and hoped that one is preferred.

So for those of you that see more insurance patients, how do know which drug is covered? Do the major insurance companies all use the same formulary? Do you accept requests to change drugs because it's not preferred?

We're still on V6.3.3 because of the vaccine coding issue, but I see that in "manage via NewCrops" window from the write scripts window, it seems there is a way to check formulary. Has anyone used this? When I search for a drug in this window, drug may say "preferred 1", "preferred 2", "on formulary" but there is no glossary that explains these terms.

When I get a fax from pharmacy saying "Rx not covered" I just ask the pharmacy to get the insurance company to take over prescribing, "ask Dr. Insurance" what he wants the patient to have. The pharmacy can look it up and give me a list of "approved alternatives" to whatever I prescribed.

I am not going to waste my time searching through formularies -- I'm not paid for that, nor is my staff.

Similarly, I don't do any "prior auth" of drugs unless I determine at the outset that is what needs to be done.

Doctors really need to push back. The insurance companies make a lot of money off our uncompensated labor.

I agree Tom. I also tell the pharmacy to tell the patient their insurance company will not pay for my drug of choice. If they want to bring me in a list of alternatives I will discuss with them if I think they are appropriate substitutes.

Maybe it's because we're in a big city, but most pharmacies here won't look up alternatives for us. They just say you have to tell me another drug and I can look up whether it's covered or not.

Before I started working in a medical practice and knew anything about this kind of stuff, I would look up my health insurance formulary myself when my doctor Rx something that costs too much. Then I asked my doc to change the medicine to something on that approved list. Unfortunately, our patients don't have the same minset...

Dear Serene--
Probably you stay that way by not making any waves.
That doesn't seem to be my personality.

The chain pharmacies are just the same here.
But I keep insisting it is my business to prescribe the best remedy I know, and not my business to promote one brand over another or save the insurance company money.

I just don't look up anything until the pharmacist tells me what is covered.

Sometimes they won't even fill the prescription -- then I throw it back on the patient to call their insurance company and find out what is covered.

I everyone pushed back, this would not be a problem -- too many doctors just cave in because it's easier.

Tom, I think your method is a good one and I wish our doctor would agree to do this.

Im dealing with this issue as well. Why is there even a tab that states "drug eligibility" when it won't work...

At least one chain pharmacy comes back with a form letter to the effect that "Drug not covered. Do you wish to prescribe one of the covered alternatives....."
And they list alternatives.
That is at least a place to start, and now I know that the pharmacies can do it.

We just have to make them do the work, not us.

I've tried using the Formulary button as well without much success. With some insurances there's no info available. With one of today's patients it said Tier 1 but turned out not to be covered. I spoke with Tech support about this and was told that the problem is with NewCrop and/or the insurance companies. I'm not convinced that the insurance companies even want us to get easy access to formulary info.

At the AC User Conference in Boston in September the word was MU Stage 2 will be coded by the end of the year. Then it needs to be approved by CMS?may take 1-2m. Stage 2 for 2014 we only have to attest for 90d so we con't have to start using it till 10/1/14.

Sorry, the above post was to the wrong thread--I've been unthreaded. :-)

Probably 80% of the drugs I use are in the Wal-Mart cheap list ($10 for 90 days). Those I don't worry about. I figure pretty much anyone can afford them if for some reason insurance rejects them.

For others, I do much like above. If a patient wants to suggest an alternative, I'll consider it. If I have to play games, I won't, at least not without an appointment. Also, I rarely do PA's except for drugs like biologicals and their insane expense. I am not going to spend 20 minutes trying to get some guy's Viagra approved.

Bravo DGrauman.

I am not part of the medical marketing program either.
When there is a reason for restricting a specific drug (expensive biologicals) and I have personally decided to prescribe it, then I will expend the effort for a PA.

If it is because someone comes in with "fibromyalgia" and a request for Savella -- well, forget the PA.