Battling the HMO Formulary
The Strategy: Learn About the Formulary
First find out exactly what kind of formulary your plan has. Some have a single formulary list. Others include restrictions on some drugs, prescribing them only for certain conditions.
Still others have a three-tier plan. These plans allow you to choose a generic drug on the formulary, a name brand on the formulary, or a drug not on the formulary at all. But, Pisano says, your co-payment goes up when you choose the name brand over the generic, and the third option costs you the most of all.
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.