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Health Care Reform:

Health Insurance & Affordable Care Act

Battling the HMO Formulary

Your health plan may not cover the drugs you want.

Ask for an Exception

If necessary, consider asking for an exception. "Our code of conduct requires an exceptions process," says Pisano. "That does not mean the drug will definitely be covered. It means the doctor can talk to the plan officials and make a case."

In some plans, the doctor himself can request an exception. Such is the case with Kaiser Permanente, says Gray. Take the scenario where you've been doing well on a drug and then switch to a different plan that doesn't include the drug in its formulary. If the doctor decides that drug is best, "he writes a formulary exception prescription," Gray says. "Unless there is a market shortage of a drug, it will be done." Once a doctor makes the decision, it stands, Gray says -- with one possible exception: Other doctors in the plan who question the decision may ask the doctor requesting the exception to reconsider.

Some managed care plans require you to try out other drugs on the formulary that are prescribed for your condition before you can ask for an exception, says Norris. She advises consumers to find out which drugs are on their plan's formulary. Most plans have a member services department you can call for this information. Citizens for the Right to Know, a nonprofit organization, also posts information on formularies of California health plans on its Web site at www.rtk.org.

Appealing the Decision

If asking for an exception doesn't get you the results you want, find out what your plan's appeal process is. For suggestions on how to appeal, see the Web site of the Health Rights Hotline, which includes sample letters on requesting coverage for a non-formulary drug.

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