Formularies, Insurance, and Parkinson’s
Navigating health insurance is challenging even for people in the best of health, but when you need a variety of medications to treat your motor and non-motor Parkinson’s symptoms, it can feel even more overwhelming to find the best coverage for you. Having a basic understanding of how insurance companies cover prescription medications, though, can help you get the care you need. Here, we’ll explore how formularies work, sharing information about how your medications are covered, how you can make the most out of your plan, and what to do when something goes wrong.
What is a formulary and how does it work?
A formulary is a list of prescription drugs that an insurance company will cover. Insurance companies and other prescription drug providers use formularies, which are continually updated, to determine what medications they will help you pay for and which are your responsibility. Formularies are developed and maintained by medical professionals who evaluate medications based on efficacy, safety, and value. Health plans update their formularies annually and make additional changes throughout the year if new medications become available or the FDA determines that a particular medication is unsafe.
Formularies include tiers, or categories, that are based on the type of drug: generic, preferred brand, non-preferred brand, and specialty. Tier 1 includes generic drugs and typically has the lowest copays. Tier 2 features non-preferred brand-name drugs, while Tier 3 usually includes preferred brand-name drugs. If Tier 4 exists in your insurance company’s formulary, it will usually feature specialty and biosimilar drugs. Medications in Tiers 3 and 4 are sometimes new or not yet established as safe or effective. Drugs can also be put into Tiers 3 and 4 if there is already a similar, less expensive medication in Tier 1 or 2. Your copays will be highest for medications in Tiers 3 and 4.
TYPE OF DRUG
|Tier 1||Generic drugs; low copay|
|Tier 2||Non-preferred brand-name drugs|
|Tier 3||Preferred brand-name drugs; high copay|
|Tier 3||Specialty and biosimilar drugs; high copay|
In short, a formulary is simply a list of many of the approved medications that are known to provide the best overall value to the patient. This way, insurance companies can be sure to offer a wide range of medications while only covering drugs with proven benefits and low risk.
Where can I find the formulary for my plan?
Usually, you’ll be able to find out which drugs are included in your plan and what tier they fall under by perusing your plan’s summary of benefits and coverage. This information is best found on your insurer’s website, and you can find your specific formulary by searching under the name of your plan, which should be available on your insurance card. If you have any trouble finding the formulary you’re looking for, don’t hesitate to call your insurance company and ask about a specific drug or request a copy of the formulary by post or email.
What if the medication I need is not covered on my plan’s formulary?
Because formularies do not include all available prescription drugs, acquiring certain medications may require jumping through additional hoops. If the medication your doctor has prescribed isn’t covered on your plan’s formulary, the first step you should take is to ask your doctor if there is a less expensive or generic version of your medication available. If there is, that medication is more likely to be covered under your formulary, and your doctor should be able to tell you if the generic version would work for your needs. If you’ve already unsuccessfully tried other medications, though, or your doctor feels that only a certain medication is appropriate for your care, your next step is appealing to your insurer directly.
Every insurer offers an exceptions process, through which you can request that a certain medication be covered. Your doctor’s office is likely familiar with the exceptions process and able to help you with a request for exception, so don’t hesitate to ask them for assistance.
Though the exceptions process varies depending on the insurance company, typically each will require a confirmation from your prescribing physician that the medication you are requesting is necessary to your care. They will also require a statement from your doctor explaining that the medications included on the formulary, even those considered alternatives to the drug you are requesting coverage for, will not treat you as well as the one you are requesting.
Other reasons your doctor could state in the request for exception include that your plan does not cover a high enough dosage or that the alternative medications that are covered will cause you harm.
You may be able to get temporary coverage for your requested medication during the exceptions process, wherein your insurer helps you pay for the medication while they determine whether to grant you the exception. And, if your doctor includes on the exception request that the case is urgent, the insurer will be required to make a decision about coverage much more quickly than if it’s a non-urgent case. (You doctor’s office will know more specifics about this timing, so remember to ask when you’re discussing the exceptions process with them.)
Because often the medications that people appeal for coverage are specialty or preferred brand-name drugs, keep in mind that even if approved for exception, there is a chance that your medication will be placed in Tier 3 or 4, meaning you’ll have a higher copay than you would for the generic alternatives your insurer might offer.
In some cases, your request for exception will be denied, and the reasons for that decision are not always clear. A denial is not necessarily the end of the road, however, because you can submit an appeal. You may ask your insurer to conduct an internal appeal, a complete and fair review of the decision, or you can request an external appeal, in which you take your request to an independent third party. Doing so ensures that your insurance company does not have the final say over your request.
What if my request is further denied?
Don’t lose hope. Even if an internal or external appeal determines that your insurer is not required to help you cover the cost of your prescriptions, you still have other options. After all, not all plans and not all formularies are created equal. For example, even within one insurance company, a certain medication could be Tier 1 for one plan and Tier 2 for another. Different insurers will also place medications in different tiers. If after the appeals process you’re still having trouble getting coverage for your prescriptions, consider exploring other plans—within your insurance provider’s other offerings or through other insurance providers—to see whether you can find your necessary medications for a lower copay elsewhere.
When you’re choosing a healthcare plan or considering switching to another insurer, don’t hesitate to shop around and ask questions about specific formularies. Questions about copays, monthly premiums, and covered providers are very important when choosing your health insurance. By comparing which prescription drugs are covered and on which tiers, you can narrow your options to make sure you’re picking the best plan for your needs.
Finally, consider leaning on your Parkinson’s community. Since there are a limited number of medications used to treat motor and non-motor symptoms of Parkinson’s, reach out to other people with Parkinson’s and share any obstacles you’ve faced related to prescription coverage. Others may have advice about which plans offer better benefits and coverage, or they may be able to refer you to other resources, including social workers and patient advocacy programs. At the very least, having the support of your community can help you navigate the intricacies and challenges of health insurance and make the most of your plan.
Listen to Amy’s Story
We recently sat down with Amy Carlson, Davis Phinney Foundation Ambassador, to discuss the issue. In this video, Amy shares her story about navigating the exceptions process when her formulary stopped covering one of her prescribed medications.
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