My drug is no longer on the formulary. What do I do?

Question:

Albeit my employer pays for my health insurance I have take the policy as an individual as a company of 1. I carefully checked that my asthma drugs were covered by Keystone Healthplan East under the Affordable Healthcare Act but now I have just gotten a notice that Advair is off the formulary (tier 3 not even tier 2 any longer). I pay a fortune for it: $200 and will probably have to pay even more now. My doctor will have to jump hoops to keep me on it. Yes, I can probably afford whatever they charge me but it seems that others will probably skip using drugs. This feels like a bait and switch. There is only one reason to remove Advair from the formulary... cost. It seems that the formulary is a cost savings mechanism not a way to manage the effectiveness of a drug. It is the most effective therapy hands down. There is no generic and I am sure in my lifetime there never will be.

Should I file a complaint with Insurance Commissioner or is it a waste of time? Thanks for listing.

-Patricia

Answer: Dear Patricia,

Insurance plans have considerable discretion in deciding which drugs to include on their formularies and the formulary tier on which to place them. However, insurance plans generally provide a process through which physicians can request exceptions for individual patients. You should ask your physician whether he or she would be willing to pursue an appeal with Keystone Healthplan East on your behalf concerning Advair. The process may be time-consuming, but exceptions are often granted. If the request is not granted, you can contact the Insurance Department. However, it would most likely intervene only if the insurance company's formulary does not include any medications that are indicated for your condition.

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Robert I. Field, Ph.D., J.D., M.P.H. is a professor of law at the Drexel University School of Law and professor of health management and policy at the School of Public Health at Drexel University. Rob and the expert panel of The Field Clinic blog are available to respond to your questions on health care.