"Formularies" can change the doctor's orders

By David Stanley

Sometimes the medicine in your pill bottle is not what your doctor originally prescribed. It's called a formulary substitution, and if it happens to you, you can most likely blame your insurance company.

If you have health insurance that includes prescription drug coverage, the pharmacy card in your wallet gives your insurance company more power over your prescriptions than you may realize. It allows the insurer--not your pharmacy--to set the price of your prescription. It may steer you to a mail-order or "network" retail pharmacy, and away from the one that's most convenient for you. It also may allow your insurance company to use heavy-handed tactics to persuade your doctor to change a prescription before it is ever filled.

Most pharmacy benefit managers (PBMs), have lists or formularies of their preferred and non-preferred medications. The idea originally came from hospitals, where the intent was to help doctors make smart and cost effective prescribing decisions. With the ability to affect prescriptions for millions of people however, insurance company formularies have become more and more a strictly financial tool. PBM's say formularies are necessary to control health care costs, while critics say that they don't improve patient care and do little to stop prescription drug price inflation.

There is fierce competition among drug companies for preferred placement on PBM's drug lists. Three leading PBMs--Advance PCS, Caremark, and Medco--have all settled lawsuits in recent years over alleged "rebates" paid by drug companies to secure places on formularies. A court decided these payments amounted to illegal kickbacks, and the "savings" were not passed along to consumers. Advance PCS has since been aquired by Caremark, and merged with drugstore chain CVS.

What does this mean for you?
Unfortunately, it means a loss of control over how your prescription therapy is managed. You may face dramatically higher out-of-pocket expenses for prescriptions that are not on your insurance company's preferred list. Some prescriptions may not be covered at all.

If your doctor decides that a non-formulary medicine is best for you, you may face a cumbersome "prior authorization" process that requires your doctor to justify why he thinks you need the medicine. The process can take days or weeks, and I have seen more than one customer give up and simply pay out of pocket for medicine.

What can you do?
Find out what your PBM's formulary policies are. There should be a customer service number on the back of your drug-benefits card. Call it and the representative will be able to tell you if your medicines are covered, and what to do if they aren't. In some cases, it may be worth going through a prior authorization.

Once a customer of mine developed a hacking cough from his insurance company’s preferred blood pressure medicine. Eventually with his doctor's help he was able to get another medication approved by his insurance company. It is escecally important for people with Medicare Part D coverage to find out if their meds are covered. Medicare has an online tool that allows you to find this information before you enroll.

Most of the time, your PBM's preferred formulary med will work just fine and will save both you and your insurance company money. However, in case it doesn't, it can literally pay, to be aware of what decisions are being made on your behalf, and by whom.

David Stanley is a freelance writer who has worked as a community pharmacist for 15 years. He can be reached at dmsrph at gmail dot com.