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[Ms. Toad]

597. Always check the formulary.

We have several medications which are covered by some companies, and not by others. Whenever we change insurance companies, the first thing we do is check to see if the critical doctors and care facilities are on the new plan. The second is to check the formulary. The third is to check the less critical doctors.

MS medication, medication for IBD (which my daughter has), and often AIDS medications are ones which a fair number of insurance companies have classified as specialty medications (typically biologics). I am surprised it caught you off guard - because it isn't the ACA, it is insurance companies in general. The last 3 insurance plans I have been on have classified my almost off patent, non-biologic, medication as a specialty drug - which means it is covered, but at a % of the cost rather than a flat fee. The current plan (as of January) has it back as a formulary-name brand drug. More expensive than most, but better. She's also on a prescription probiotic - nearly as expensive as your wife's medication. Fortunately, two of the last three have covered it - but the two prior to that didn't.

Appeal. Most insurance companies have an appeal mechanism based on medical need. You will need strong doctor advocates on your side - and you may have to step through (or document that you already have) first/second tier medications to prove they don't work and your wife needs the medication she is on. We've had to do it both ways - repeating trials of medicines or procedures that hadn't worked, and merely documenting that we had already tried it. That run-around is partly because they figure no one will bother and it saves them money - but there is a medically valid reason as well. Doctors are susceptible to marketing - and they may be prescribing medication that is more costly (and sometimes less proven) than other less splashy medicines with big advertising bucks behind it. Having a process of walking through a protocol verifies that the pricier medication is really the best balance of cost v. benefit.

Finally - check to see if the pharmaceutical companies have a compassionate care program. They often offer free or substantially reduced cost prescriptions.

Good luck - and when open enrollment comes around, check the formulary!