How do I convince my insurance company that I cannot use its formulary alternatives? I have been suffering from an injury for 15 years, and I have a long list of medications that I have tried and cannot use for one reason or another. That includes a lot of the insurance company's formulary alternatives. I have to battle with my insurance company every time I have to take a nonformulary drug. I have filed papers, talked, and have had cooperation from my doctors, and I'm still butting heads with the insurance company. I am thinking of changing companies, but how can I find out details of a company's medication coverage in advance?

J.

In the world of prescription drug coverage, there is a variety of benefit designs and structures, and not all work equally well for participants. Some prescription drug coverage pays for all pharmaceuticals, but requires a lower co-pay for generic drugs and a higher co-pay for name-brand drugs. Other drug plans use a drug formulary: a list of certain pharmaceuticals it will cover for various medical conditions. Since the formulary is a part of the insurance contract, the carrier may be under no obligation to go beyond contractual provisions.
The formulary list is normally determined by a team of physicians. They try to choose drugs with proven track records that will address each set of symptoms or medical condition. Cost is only one factor in determining which drugs are part of the formulary. Other factors are safety, reliability, side effects, etc. The problem is that not all drugs are on the formulary, and the one your doctor prescribes for you may not be on that list, while those on the list may not provide acceptable relief.

Drugs are expensive. People with prescription benefits are fortunate, because a drug plan makes medications more affordable. Implementing a formulary is one way of establishing a safe treatment protocol, but it also helps to keep the cost of providing prescription drugs as low as possible. Even so, we are seeing a gradual diminishing of group plans with drug benefits.

Some drug plans with a formulary will cover non-formulary drugs, but they require the patient to cover the cost difference between the formulary drug and one not on the list. Still, remember that the formulary also serves to establish a standard, safe protocol that protects the health plan from lawsuits resulting from negative results of new or experimental drugs.

Many companies will work with policyholders with special needs, even though they are not required to do so. It appears that you have done the extra work necessary to seek the results you desire. As long as your coverage has a formulary and your doctor prescribes drugs not on the list, you will have to plead your case. At the same time, you should give your physician a copy of your formulary so she or he can consider drugs on the list.

If this type of coverage will not continue to meet your needs and you have the option of switching to other coverage that includes prescription drugs, you can determine the type of coverage ahead of time. Simply ask for an explanation of the drug coverage or a copy of the drug benefit provisions. If there is a formulary, obtain a copy and compare it with your current coverage. There is no reason why you cannot get complete information on any provision of a potential coverage plan.