So let me see if I've got this straight...

[Chan790]

437. ...and under it, Will would most-likely still be getting initially rejected.

Medicare uses formularies. So does Tri-Care; Medicaid; the British, French, German and Canadian National Health Services; virtually all private insurers and every single healthcare proposal put forward in the United States since LBJ was in office. (For the most part, those formularies are fairly similar...the decisions to include or delist a medication are typically based on scientific studies and all formulary-review boards have access to the same data. They're usually not this controversial.)

It's the best medical solution to actual issues of cost containment and best outcomes, that's why it's a universal solution. Lots of things don't get covered because they're expensive and they work less-well than a cheaper option. I daresay that's the way it should be.

I feel bad for him and there is a process to obtain coverage...but it's a pain in the ass. He needs to work the system. This isn't an ACA issue or an Obama issue...it's really a patient-care issue. He'd be dealing with it even if we'd enacted Medicare for All or a National Health Service single-payer model. If it's really the best drug for Mrs. Pitt, she'll get the medication. Ideally, they should have covered it during the review...that's a good fix for when we fix Obamacare down the road, mandating coverage of previously-covered medications during appeals and reviews. That patients would be kicked off their meds pending review is an outcome that should have been foreseen.