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From Seattle, Washington, USA:

Three months ago, my health plan signed a deal to switch brands of insulin to which I had an adverse reaction. My doctor is switching me back to my former brand, but the health plan is making it stressful and claim they will make me pay larger co-pays and have regular "reviews" of my prescriptions which may cause delays when they will be filled. They actually tried to insist I use up the rest of the new insulin I had! Have you heard of this kind of treatment by other health plans?


Many health plans are creating arrangements with preferred pharmaceutical manufacturers; these are called exclusive formularies. Generally, insureds are required to pay higher copays or cover the cost of items and medicines not on the plan's formulary. The plan contract probably provides for higher copayments or coinsurance requirements for drugs and items not on their formulary. You are entitled to file a written appeal to the decision of the plan. This appeal should contain documentation from your physician of your adverse reaction to the new insulin. You must follow the timelines and requirements established by the plan to proceed with your appeal. Unfortunately, in your description you did not mention if your plan is self-administered/self-insured. If so, these plans are literally unregulated and patients are left to beg and plead for coverage when the plan administrator denies a claim. Your best bet is to have your physician document your adverse reaction to the preferred insulin. With that in hand seek a meeting with the plan medical director or benefit administrator. One alternative might be to have the plan fill your insulin needs through a mail order pharmacy provider. If your plan is subject to state regulation, I would again have your physician document your adverse reaction to the preferred insulin while also seeking a meeting with the plan medical director. If they will not meet with you or fail to cover your insulin,file a complaint with the Washington State Office of the Insurance Commissioner. Their telephone number is 1-800-562-6900. Keep in mind that if you are given a choice of health plans, you might want to change at the next open enrollment period.


Additional comments from Dr. Jim Lane:

With regard to the way you have been handled by your insurance, I would recommend you contact your state representative, U.S. Congressman, or U.S. Senator to let them know how your are being handled. Also, States often have an insurance council or oversight body that can field complaints of poor consumer treatment. I would suggest you look into one of these venues for further feedback and response.


[Editor's comment: I believe that your insurance company is putting you at risk. If you have an adverse reaction to a medication, they certainly cannot insist you continue to use it.

I would have your doctor write a letter, or speak to your case manager and/or the Medical Director, outlining your problem and requesting an exception for you to go "off formulary" with your usual co-pay. This is typically honored.

Until things get resolved, you should request sample vials of your insulin from your doctor and/or the company representative. They should be readily available and tide you over. SS]

Original posting 21 Jun 2002
Posted to Insurance/Costs


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Last Updated: Tuesday April 06, 2010 15:09:34
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