ACA question..

[iamthebandfanman]

I just had a friend tell me her child was diagnosed ADD (after months of going to multiple people to make sure) .. the physician prescribe a medication to her child and her insurance company refused to pay for it and instead insisted that she take a cheaper drug.. I asked if she meant a generic and she claims she was forced to get a different drug altogether because of the costs (a cheaper one picked by the DR, not the one originally prescribed)... is that possible?
if so,
will the plans in the ACA change this so parents can have the drugs they want and are prescribed by a physician they trust?

any advice I should give my friend ?
(she is married, one child)

[lostincalifornia]

1. So what you are saying is that the insurance company is essentially overriding the Doctor?

[NYC_SKP]

2. Hard to say, neither of you are doctors, and you say the doctor selected the cheaper prescription.

I don't see the problem.

Probably, the doctor selected a generic version of the more costly brand, or they selected an alternative medication with the same medicinal value.

Why the fuss?

And, AFAIK, ACA will not change this; not every brand of every drug will be covered by plans-- there is no such coverage requirement in ACA.

[iamthebandfanman]

5. because the dr had prescribed a different

drug originally, and the insurance company denied it and wanted a different drug in its place... and no, it isn't a generic.. it a different drug.

shouldn't the DR be deciding which drug is best instead of having to go by what was acceptable to the insurance company?

[NYC_SKP]

7. The doctor DID make the decision, she or he selected a different drug with same purpose.

This has always been how it's done.

I'm 56 years old and there have been plenty of times that my pharmacist points out that a prescription won't be covered, or will have a higher co-pay, and then makes a suggestion for either a different drug (Azithromycin instead of Erthromycin, for example) and calls the doctor and the doctor approves the alternative.

It's not a new thing, it's not a big deal.

Different plans cover different meds differently it has ALWAYS been this way.

Sure, in the perfect world EVERYTHING would be covered, no matter the cost, but that's not the real world.

In the end what matters is the child with the diagnosis of ADD.

What are these two different drugs, by name???

If we knew, we could make an informed decision or have an informed opinion, but we don't so it's all speculative.

I hope the diagnosis is correct and that the treatment is successful.

[Chan790]

13. It's called a formulary list.

Insurance plans have lists of medications that they will pay for based on cost and previous effective results. Drugs that are not covered are those where the cost is typically more substantial than an equivalently effective medication...often pushing the generic over the name brand but occasionally one brand over another..or those where the efficacy is in question or have not been on the market long enough to establish an effective track record. Often insurers will through the appeals process, permit to cover the non-formulary non-experimental medication where (and only where) all formulary options have shown to be ineffective.

Doctors have access to these lists and are supposed to use them in the process of prescribing medications that will be covered but sometimes get confused on which insurers list they're looking at or look at the wrong year or simply make a mistake. Typically for any condition, the doctor has 3-18 different medications to choose between provided there are that many options available. While it may seem like a PITA, it goes a long way to reining in the already high cost of medication; a medication that is substantially more expensive than its competitors but does not appear to be more effective will be dropped from formulary...this pretty much insures that the medication will see a substantial sales drop until it corrects its cost to be in line to the market or develops a more effective version. Medications that have not been shown to be effective will be passed over for those that have.

This is actually precisely the sort of practice among insurers and care-providers that the ACA should encourage...it achieves cost-control and promotes effective outcomes without negatively affecting patient-care.

[PoliticAverse]

3. If the Doctor recommends a specific drug and the plan won't cover it your friend can appeal

the decision (appeals are provided for by the aca).

See: http://www.hhs.gov/healthcare/rights/appeal/appealing-health-plan-decisions.html

[lumberjack_jeff]

4. Some ADHD meds are ridiculously expensive.

If he was just diagnosed, it probably makes some sense to try the cheaper drugs first.

[Hoyt]

6. I'd research the two drugs and appeal if there is a compelling reason to use the more expensive one.

Last edited Wed Nov 27, 2013, 02:58 PM - Edit history (1)

One of the problems with our health care system is that there are very expensive drugs which do little more than much cheaper, older drugs. For example, some older drugs you have to taken twice a day. A drug manufacturer then produces basically the same drug that is time-released such that only one is needed, but it costs 5 times the older drug.

Pharmaceutical companies pay pretty people to meet with doctors and push their more expensive drugs. Sometimes the detail reps provide good info, sometimes they are just inflating the cost of health care.

As patients we can do our part to help control health care costs. One good thing under ACA is the insurance companies no longer get to pocket all savings under the Medical Loss Ratio provisions.

[Lex]

8. The first one the doctor picked? That doc could be getting swag from that company.

You just never know exactly why doctors sometimes pick a more expensive drug when a similar one that costs much less is available.

In any event, she can always appeal the decision with her insurance company.

PS -- This kind of thing was around WELL BEFORE the ACA.

[RBInMaine]

9. ADD is WAY OVERDIAGOSED. She needs to parent her kid right, limit fat and sugar, and teach her kid

to have sustained attention. That means minimal TV and electronics, and more playing board games, cards, arts and crafts, learning a musical instrument, reading books, etc.

[alc]

10. we won't know for a while (years)

In the past, the doctor and insurers had to agree. I've had my insurance turn down my son's doctor's drug recommendation until 6 months of the recommended drug not working - before the ACA. Nothing has changed there, but we will now have the IPAB.

In the past, state regulators could require insurers to provide certain levels of drug coverage and would need to negotiate with insurers about premium increases associated with that change. Now we will also have IPAB and we have no idea how they will operate. Their goal is to keep premiums down for Medicare. They COULD mandate a cheaper drug for ADD. Who knows if they will. They don't have control of ACA policies, but following their lead is the "safe" thing for insurers to do. Insurers won't be accused of gouging consumers by paying for too much medical care (turning the MLR around to increase profit) and if anyone complains about the level of coverage they can say it's approved by the IPAB.

Obama, Pelosi, etc all tell us not to worry about the IPAB - they would never do something like that. They also say if anyone feels mislead by the "you can keep your policy" promise it was the policy-holder's fault for misinterpreting the promise. Let's hope we aren't misinterpreting the statements about the IPAB.

We do know that medical costs are and will be a major concern (especially for Democrats running in 2014 and 2016). But we have no idea how all of the parties will work together (or work against each other)

[etherealtruth]

12. this has nothing to do with the ACA

insurance companies have formularies of drugs they will cover and at what rate the will cover them.

This is an article from 2009, old but explains drug formularies pretty well