This message was self-deleted by its author

[Ms. Toad]

614. That is not correct.

The last 4 plans I have been on have had a specialty drug category - and in each case I was able to check the coverage and price I would be charged. They cannot, of course, tell me whether an appeal of something which is not part of their formulary or specialty drug list will be approved prior to purchasing the plan - since that is based on unique medical circumstances. But they can (and in my experience always do) tell you the list if you ask.

And, FWIW, I have never lost an appeal (we are billed $60-100,000 a year - so you can imagine I have lots of encounters over insurance issues). In my 30 years of dealing with insurance companies, I have decided not to pursue two claims - out of network co-payment for an air cast which I would have had to drive 100 miles to find in-network, and authorization to see a pediatric (as opposed to adult) orthopedic specialist in connection with a break near a growth plate. Both were related to a doctor I fired for her refusal to assist in the corresponding appeals. I have been successful in obtaining approval for 2 experimental treatments (one surgical, one pharmaceutical), access to numerous step therapy treatments, in network treatment for costly care by an out of network specialist, family coverage for our same gender family (at a 30% reduction in out of pocket expenses) - and many more.

I agree - it should not be so hard, and it has robbed time I could have spent being present for my ill family members. But information, and successful appeals, are possible.