Parish Nurse News
Sheila Griffin, RN

Health Insurance

Health Insurance has a way of throwing curve balls at us from time to time. One of the biggest examples of this happens with your provider changes whether or not they are going to continue to cover certain medications. Insurers are permitted to add, drop, or change the tier (or cost) of a prescription at any time.

Drug plans have what call formularies. This is a list of the medications that are covered by the plan. This list is divided into "tiers". This governs how much the consumer will pay for the drug, usually through a co-pay. Most plans have four tiers. Tier 1 is usually generic drugs. This carries the lowest co-pay. Tier 2 covers "preferred" brands. Tier 3 may be "non-preferred" brands. The higher the tier the medication is in, the higher the co-pay.

Sometimes a medication is dropped from the formulary list altogether or placed in a higher tier. But what if your medication falls into this scenario? What can you do?

First of all, you can ask your physician about a substitute medication. Your plan should notify you in advance about formulary changes that will affect your medication and should offer you a reasonable alternative. Be sure to have your doctor advice to make sure the replacement medicine is as effective and safe.

Secondly, if there is no appropriate available alternative, your doctor can ask your insurer to cover your medication because it is "medically necessary". This is known as "prior authorization".

Thirdly, consider step therapy. Before considering your doctor's request for coverage, your insurer may require "step therapy". Here you must try another usually less expensive drug first. If the substitute medication doesn't work will or causes side effects, your doctor should again ask your insurer to cover the more expensive medicine.

Fourthly, consider filing an appeal. If you are still getting a no from the insurer, you have the right to appeal the decision. To file, you or your doctor will complete an appeals form from the insurer and/or write a letter explaining who you need the medication covered. This may also include supporting documents such as medical studies or more notes from the doctor. If the insurer still denies the appeal, you can file for an independent review with your state's insurance regulator which will make the final decision.

Finally, shop around. Prescription costs vary widely from one pharmacy to the next. Many chains and big box stores offer hundreds of generics at a low cost. Costco's pharmacy does not require membership.

Have a wonderful summer.

Laugh of the Month: What school do you have to drop out of in order to graduate? Parachute School.

Take care and God Bless,



The following sources are intended as a partial list of many areas in the health field where information can be obtained. There are so many sources of information that to list them here would be impossible. If there is an area you are interested in that is not listed here, please contact me and I will be more than happy to assist in getting that source for you.

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