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Post by cropaholicnora on Jun 30, 2014 19:10:10 GMT
Who should decide what prescription medications are covered under a medical insurance plan? How should they decide? This is obviously a spin-off of the Great Hobby Lobby Debate.  Some of the comments on that thread got me to thinking about this topic. I will admit up front that I don't think I have an answer to this question. In fact, I don't believe there is a "perfect" solution to this. It seems like ideally if your doctor prescribes it, it should be covered. Unfortunately, we do not live in an ideal world so it isn't that simple. There are financial considerations, because some medications are expensive and that "risk" has to be distributed across the pool and can affect premiums. Obviously, there are ethical considerations for some people/providers/companies such as contraception. Potential alternative treatments that have different pricing structures or work differently would have to be considered. Then there's the whole topic of "off-label" uses for medications. |
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Deleted
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Post by Deleted on Jun 30, 2014 19:21:59 GMT
I personally do not think an employer should be allowed to exclude classes of drugs from their insurance. What is prescribed is a medical decision between a person and their physician.
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Deleted
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Post by Deleted on Jun 30, 2014 19:44:36 GMT
Unfortunately drugs are not free. And there can be relationships between drug reps and doctors that would skew what is "needed" and prescribed. Doctors might just keep prescribing until they find what works without thinking of the bottom line cost. Someone has got to look out for the cost component.
If it isn't the employer or the insurance company, I am not sure we want it to be the doctor. Drug companies want to make a profit. So unless you have a government-regulated price chart of drugs, I am not sure that costs could be contained. And you can bet if the gov't is controlling it, there will be limited access and lots of paperwork to get the more expensive drugs. And some of the drug-makers will just get out of the market with too much regulation or price-control. And you can bet the drug-makers will want more limited liability in lawsuits in return.
That said, I think each individual should decided what level insurance and rx's that they want to cover and what their copay/deductible would be. Much like car insurance. There is a minimum coverage (basically catastrophic) all the way up to no deductible/full coverage for anything. Right now this is pretty much decided at the employer level with some employers having multiple plans and giving the employee the choice. But many just have one plan and it is what it is.
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Post by annabella on Jun 30, 2014 19:45:42 GMT
I personally do not think an employer should be allowed to exclude classes of drugs from their insurance. What is prescribed is a medical decision between a person and their physician. Exactly. It's not my employer's business what I take or for them to regulate my private life. |
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Post by cropaholicnora on Jun 30, 2014 19:49:00 GMT
Unfortunately drugs are not free. And there can be relationships between drug reps and doctors that would skew what is "needed" and prescribed. Doctors might just keep prescribing until they find what works without thinking of the bottom line cost. Someone has got to look out for the cost component. If it isn't the employer or the insurance company, I am not sure we want it to be the doctor. Drug companies want to make a profit. So unless you have a government-regulated price chart of drugs, I am not sure that costs could be contained. And you can bet if the gov't is controlling it, there will be limited access and lots of paperwork to get the more expensive drugs. And some of the drug-makes will just get out of the market with too much regulation or price-control. That said, I think each individual should decided what level they want to cover and what their copay/deductible would be. Much like car insurance. There is a minimum coverage (basically catastrophic) all the way up to no deductible/full coverage for anything. Right now this is pretty much decided at the employer level with some employers having multiple plans and giving the employee the choice. But many just have one plan and it is what it is. The concept of how drug companies "lobby" doctors to prescribe their drugs is pretty scary to me. I hadn't considered the possibility of running prescription drug coverage like car insurance, but that's an interesting concept. I definitely think that warrants consideration. |
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Post by Deleted on Jun 30, 2014 19:49:23 GMT
I personally do not think an employer should be allowed to exclude classes of drugs from their insurance. What is prescribed is a medical decision between a person and their physician. Exactly. It's not my employer's business what I take or for them to regulate my private life. It is if they are the ones paying the claims and the difference between the real cost and what you are paying in a copay. It seems everyone wants everything covered but wants the employer to pay for it all with low deductibles, copays and premiums. Without realizing the true cost.
People who feel this way should go ahead and hop onto an ACA Marketplace plan outside of their employer and see what the premium would be along with the copays and deductibles. It would give you a good idea on how much the employer is already subsidizing.
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Post by Deleted on Jun 30, 2014 19:52:09 GMT
The concept of how drug companies "lobby" doctors to prescribe their drugs is pretty scary to me. I hadn't considered the possibility of running prescription drug coverage like car insurance, but that's an interesting concept. I definitely think that warrants consideration. Me too! Just look at how much is spent on TV ads to market specific drugs. I do think there was a law a while back that tried to control what kickbacks drs got from the pharm reps....not sure if they found another way around it though. It does feel like there are more ads to convince the regular population that they NEED a specific drug. So they will go to their drs and ask for it. Rather than letting the dr prescribe what they feel is needed. |
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sheepea
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Post by sheepea on Jun 30, 2014 19:53:44 GMT
One of the reasons why I think health insurance should not be tied to anyone's job. If your employer is paying for it, they will always have some say over your health.
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Post by birukitty on Jun 30, 2014 20:41:27 GMT
I think the decision for what drug should be prescribed should be between the doctor and the patient. We are talking about people's lives, their bodies, their medical histories, their ailments, their diseases, and a million other things. The doctors went to medical school and are experts at choosing what drug best benefits that particular patient sitting in their office while the doctor is holding the patients medical records in their hands. In many cases the doctor has seen the patient before (in my case for years). The medication my doctor chooses has to do with what will work best for me in that particular case based also on whatever else I am currently taking.
Along comes my health insurance company who says "No" we aren't going to cover that medication, we're only going to cover this other medication (which the doctor did NOT prescribe) because it's cheaper. Maybe he didn't prescribe it because it will interact with the other 4 medications I am taking. He has his reasons. The health insurance company doesn't care. Even though I'm paying over $1,000 a month for health insurance. The only way I can get the medication the doctor prescribed that I truly need is to pay for it out of pocket-so why the heck am I paying $1,000 a month for this horrible medical insurance in the first place that gets to decide on a whim what they will or will not cover? They decide based on COST. What will cost them the least is what they will cover and what will cost them the most they won't.
This is wrong! It is a terrible way to run health insurance. DH just got a new job and for the first time we have no choice of health insurance coverage-all employees get the same company and the same coverage.
I think health insurance should be on an open market just like car insurance or home owner's insurance. They should have to compete for our business. And it should not be tied to our employers at all. If they had to compete it would drive down these horrible inflated costs and it would bring up the benefits. As it is they can do whatever they wish.
Debbie in MD.
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quiltz
Drama Llama
Posts: 6,689
Location: CANADA
Jun 29, 2014 16:13:28 GMT
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Post by quiltz on Jun 30, 2014 21:58:50 GMT
With our insurance (Canada), the insurance company decides what is covered and what isn't covered.
Medications are not "free" in Canada, hospital care is covered but not meds. Meds are covered while you are in the hospital but once you leave the facility, you or your insurance pays for the meds.
There are even some meds (mainly cancer related) that are not covered in hospital because they are simply too expensive.
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Post by scraphappyinjax on Jun 30, 2014 22:04:08 GMT
I personally do not think an employer should be allowed to exclude classes of drugs from their insurance. What is prescribed is a medical decision between a person and their physician. Exactly. It's not my employer's business what I take or for them to regulate my private life. You are exactly right if you have a private plan and are taking on the financial responsibility. |
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Post by justkallie on Jun 30, 2014 22:05:57 GMT
Exactly. It's not my employer's business what I take or for them to regulate my private life. You are exactly right if you have a private plan and are taking on the financial responsibility. Exactly. As long as someone else is footing the majority of your coverage, you are at their mercy of their decisions. |
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Post by grammyj64 on Jun 30, 2014 22:23:52 GMT
If your doctor prescribes it, it should be covered. I can see needing to explain very expensive or experimental drugs, but it should be between the doctor and the insurance company with no input from the employer.
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Post by scraphappyinjax on Jun 30, 2014 22:35:39 GMT
If your doctor prescribes it, it should be covered. I can see needing to explain very expensive or experimental drugs, but it should be between the doctor and the insurance company with no input from the employer. But your employer is taking on the majority of the cost of the insurance plan. Wouldn't you, as a business owner, want to be able to make decisions as to what you're spending your money on? I agree that health insurance should be determined by individuals but the way our healthcare system is right now, that's not the case. That's why America needs true healthcare reform. What Congress pushed through with Obamacare/ACA isn't the answer and unfortunately it's only going to get worse, in my opinion. |
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Post by nightnurse on Jun 30, 2014 22:47:03 GMT
I did a whole big report on direct to consumer advertising of drugs and how it drives up costs. Only two countries in the world allow it-us and New Zealand. As for drug reps influencing medical professionals, it's much better than it was. When I started in health care 15 years ago, the doctors got all sorts of perks-sports tickets, vacation rentals, etc. Then it became meals and pens. For a solid year, I didn't have to buy a pen or my own lunch. That has decreased, too, can't even get a free pen anymore! Your provider doesn't pick a drug willy nilly-we use established guidelines and recommendations, current literature, past experence and sure, there is some subconscious stuff going on, we're as susceptible to that as anyone else. But I do know what your insurance prefers, and try to stick with that. With patients you have an established relationship with, you know if cost is a concern and can offer choices, like maybe this acne med works the best, but it'll cost twice as much, which would you prefer type of thing. Your provider isn't making the decision based on who bought the best lunch, but which drug is the right fit for you and if he/she isn't, then you need a new provider.
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Post by M~ on Jun 30, 2014 23:05:45 GMT
I don't think that just because a doctor prescribes a drug that it should be covered. I work in the health law field and often see things that have no proven therapeutic benefit or are prescribed for non FDA approved uses (in the case of drugs). I think insurance plans have the right to set parameters as to what is covered and what isn't.
I'll give you a perfect example: chemotherapy drugs or cancer treatments. This is the most common class of drugs and treatments that are prescribed for non-FDA approved uses or for uses that have no shown therapeutic benefit. These cases break my heart, but we just can't approve every drug for every use or every procedure for every use.
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Post by epeanymous on Jun 30, 2014 23:12:40 GMT
I, personally, am completely comfortable with my employer making my medical decisions. I am particularly happy where, as here, the employer changes what they are willing to cover. I can't imagine what could go wrong.
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Post by Anna*Banana on Jun 30, 2014 23:14:54 GMT
Insurance plans vary in meds all the time. They'll frequently not cover non-generic. Mr. AB has an Rx that will only be covered by his insurance if its the generic. He's allergic to something in the generic but not the name brand. We're on our own for the Rx because of that. Insurance plans and the companies that negotiate coverage, decide what is available in it all the time. There are drugs and treatment plans for say, cancer that a plan will not include. I've seen that right here with the peas. Drs. work within these parameters all the time.
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Deleted
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Apr 26, 2024 20:01:31 GMT
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Post by Deleted on Jun 30, 2014 23:23:27 GMT
Unfortunately drugs are not free. And there can be relationships between drug reps and doctors that would skew what is "needed" and prescribed. Doctors might just keep prescribing until they find what works without thinking of the bottom line cost. Someone has got to look out for the cost component. If it isn't the employer or the insurance company, I am not sure we want it to be the doctor. Drug companies want to make a profit. So unless you have a government-regulated price chart of drugs, I am not sure that costs could be contained. And you can bet if the gov't is controlling it, there will be limited access and lots of paperwork to get the more expensive drugs. And some of the drug-makers will just get out of the market with too much regulation or price-control. And you can bet the drug-makers will want more limited liability in lawsuits in return. That said, I think each individual should decided what level insurance and rx's that they want to cover and what their copay/deductible would be. Much like car insurance. There is a minimum coverage (basically catastrophic) all the way up to no deductible/full coverage for anything. Right now this is pretty much decided at the employer level with some employers having multiple plans and giving the employee the choice. But many just have one plan and it is what it is. I am the "someone" who is responsible for looking out for the cost component. More than once, I've addressed cost of medication with my doctor and we've made adjustments. Recently, my BP meds increased to cost me over $400 for a 3 month supply. I went to the doctor and got a new prescription. (new prescription has brought me many negative side effects...have another appointment tomorrow to discuss my options...including ordering my prescription from Canada...at a 3 month cost of $288. Still expensive as shit...but at least it's not over $400 and at least I know it works and doesn't leave me feeling so poorly) I don't leave it up to my health insurance company, prescription provider or even my doctor alone to figure out what's best for me both medically and financially. I take ownership of problem solving. |
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Deleted
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Post by Deleted on Jun 30, 2014 23:25:01 GMT
Ughh...having issues trying to quote. Anyway...here's my part of the above post that I tried to quote luvspaper and now it just looks like she said my reply
Here's MY response to luvspaper in regards to someone needing to be on the look out for the cost component
If it isn't the employer or the insurance company, I am not sure we want it to be the doctor. Drug companies want to make a profit. So unless you have a government-regulated price chart of drugs, I am not sure that costs could be contained. And you can bet if the gov't is controlling it, there will be limited access and lots of paperwork to get the more expensive drugs. And some of the drug-makers will just get out of the market with too much regulation or price-control. And you can bet the drug-makers will want more limited liability in lawsuits in return.
That said, I think each individual should decided what level insurance and rx's that they want to cover and what their copay/deductible would be. Much like car insurance. There is a minimum coverage (basically catastrophic) all the way up to no deductible/full coverage for anything. Right now this is pretty much decided at the employer level with some employers having multiple plans and giving the employee the choice. But many just have one plan and it is what it is. I am the "someone" who is responsible for looking out for the cost component. More than once, I've addressed cost of medication with my doctor and we've made adjustments. Recently, my BP meds increased to cost me over $400 for a 3 month supply. I went to the doctor and got a new prescription. (new prescription has brought me many negative side effects...have another appointment tomorrow to discuss my options...including ordering my prescription from Canada...at a 3 month cost of $288. Still expensive as shit...but at least it's not over $400 and at least I know it works and doesn't leave me feeling so poorly) I don't leave it up to my health insurance company, prescription provider or even my doctor alone to figure out what's best for me both medically and financially. I take ownership of problem solving.
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Deleted
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Post by Deleted on Jun 30, 2014 23:30:17 GMT
OMG...it's still not right. I need a drink...or a nap.
Here's my next quote to respond to.
Along comes my health insurance company who says "No" we aren't going to cover that medication, we're only going to cover this other medication (which the doctor did NOT prescribe) because it's cheaper. Maybe he didn't prescribe it because it will interact with the other 4 medications I am taking. He has his reasons. The health insurance company doesn't care. Even though I'm paying over $1,000 a month for health insurance. The only way I can get the medication the doctor prescribed that I truly need is to pay for it out of pocket-so why the heck am I paying $1,000 a month for this horrible medical insurance in the first place that gets to decide on a whim what they will or will not cover? They decide based on COST. What will cost them the least is what they will cover and what will cost them the most they won't.
Here's my response. If there is a valid reason why you're unable to take the drug they want you to take, your doctor can submit a request for them to cover it and explain why THAT is the drug you need. I've had this happen numerous times (usually the "approval" only lasts a year) and my insurance company has never EVER denied to cover a drug if my doctor tells them that I do in fact need it.
What they're trying to do is make sure you've tried the cheaper alternatives. It's a cost saving measure. Even though I've been impacted by this plenty (including my medication going up to over $400 for a 3 month supply) I understand why they do it and although it's a PITA to get my doctor to submit a request to them, I do it and my doctor does it...for me and countless others. It's not that abnormal.
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Post by birukitty on Jul 4, 2014 19:01:50 GMT
It's not abnormal. But it's wrong. I've been through it a dozen times with my insurance company. It's takes them 12-15 BUSINESS days to make the approval for the drug that the doctor has prescribed that I need. I can't take the other one-that is the one I absolutely have to have. I've been with this same doctor for several years. He knows my medical history. He knows what drugs interact with all of the other medications I'm taking. He has the medical degree.
Not the insurance company! All they want to do is deny it because-oh, gee that one is the expensive one. Sorry we don't cover that. So I have a choice. Pay out of pocket for the medication I have to have in the meantime hoping (yeah right) they'll eventually reimburse me, while at the same time I'm paying these jerks over $1,000.00 a month.
They deny more and more medications every month in the hopes that people will give up and not go through the paperwork. What will be the result? People (and their doctors) will be forced to choose alternative medications that aren't the correct fit just so that they are covered by the health insurance companies. This is so wrong. It's ass backwards. Patients and their doctors should be deciding their medications. Not insurance companies!
One of my medications is $502.00 a month. Thanks to our new health insurance we now have a $5,000.00 deductible, so that will be coming out of our pocket. I can't take the generic of that prescription. I tried for the past 8 years and it doesn't work for me.
I agree-our health insurance system is broken. I keep thinking it could be worse because that's how I live my life, but it's tough.
Debbie in MD.
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Some of the comments on that thread got me to thinking about this topic. I will admit up front that I don't think I have an answer to this question. In fact, I don't believe there is a "perfect" solution to this.
