I think one look at Medicare and Medicaid would convince anyone why government-run health care is bad.
Most insurance plans are a compromise. They'll cover, say, one drug or a few in a class, but not all of them. Or they won't cover a class entirely, if it's not considered medically neccesary or any better than non-prescription (OTC) drugs.
For example: Viagra. Some insurances cover a limited amount per month, and some don't cover it at all. Ambien, a popular sleep med. Some insurances cover a short duration, and some tell you to use Benadryl (OTC). Cough Syrups. Mass Medicaid won't cover them, since they've never been proven to be any more effective than OTCs--whose efficacy is also questionable--but it will cover vaporizers. Infertility Drugs. Some cover them completely, some cover only the (cheap) non-injectable ones, and some don't cover any. Heart & cholesterol meds. Most insurances don't cover every drug in these classes, due to costs. Early refills. Most of the time unless you're going out-of-country, you're out of luck. Brand vs. generic. The brand is almost always more, and some insurances don't cover it at all.
So what do you do when your med isn't on the list? Most insurances have an appeal process, called prior approval; this can only be done by your doctor talking to the insurance. Most docs don't want to spend that time, and the insurance company is counting on it--they'll change the drug instead. Or you will give up on the script. And once you get a PA, you'll have to keep getting it--biannually or annually or even monthly. Sometimes it involves bunches of paperwork.
If it were up to pharmacists, we would be happy if all prescriptions were covered, and cost the same for everyone. But in reality, there's several thousand plans out there, and no way to know what's on their formulary until we submit the electronic claim. And then, if it's rejected, we try our hardest to figure out why & do something about it. But sometimes, we can't win. We're as much at the mercy of the insurance providers as anyone. So please, don't take it out on your pharmacy: go to the source.
no subject
Most insurance plans are a compromise. They'll cover, say, one drug or a few in a class, but not all of them. Or they won't cover a class entirely, if it's not considered medically neccesary or any better than non-prescription (OTC) drugs.
For example:
Viagra. Some insurances cover a limited amount per month, and some don't cover it at all.
Ambien, a popular sleep med. Some insurances cover a short duration, and some tell you to use Benadryl (OTC).
Cough Syrups. Mass Medicaid won't cover them, since they've never been proven to be any more effective than OTCs--whose efficacy is also questionable--but it will cover vaporizers.
Infertility Drugs. Some cover them completely, some cover only the (cheap) non-injectable ones, and some don't cover any.
Heart & cholesterol meds. Most insurances don't cover every drug in these classes, due to costs.
Early refills. Most of the time unless you're going out-of-country, you're out of luck.
Brand vs. generic. The brand is almost always more, and some insurances don't cover it at all.
So what do you do when your med isn't on the list? Most insurances have an appeal process, called prior approval; this can only be done by your doctor talking to the insurance. Most docs don't want to spend that time, and the insurance company is counting on it--they'll change the drug instead. Or you will give up on the script. And once you get a PA, you'll have to keep getting it--biannually or annually or even monthly. Sometimes it involves bunches of paperwork.
If it were up to pharmacists, we would be happy if all prescriptions were covered, and cost the same for everyone. But in reality, there's several thousand plans out there, and no way to know what's on their formulary until we submit the electronic claim. And then, if it's rejected, we try our hardest to figure out why & do something about it. But sometimes, we can't win. We're as much at the mercy of the insurance providers as anyone. So please, don't take it out on your pharmacy: go to the source.