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This kind of shenanigans from the insurance companies is becoming increasingly common. Your doctors are powerless in fighting it, as the driving force is economic. It does affect the quality of care, since doctors are sometimes forced to prescribe medicines that will be covered in the formulary, and not their first choice. Appeals within the insurance industry itself are time consuming, and most often unsuccessful - a "sandbox" mentality. The only way to stop this kind of nonsense is for the public to complain about each and every action of this type to the appropriate authorities. 1) Your elected representatives 2) Your state Insurance commissioner 3) Your employer (who is responsible for negotiating your Health Insurance Contract) JAR ----- Original Message ----- From: "Arthur Hirsch" <[log in to unmask]> To: <[log in to unmask]> Sent: Saturday, April 15, 2000 7:38 PM Subject: Formerly Formulary > I had been getting my meds through a pharmacy owned by my insurance > provider, Texas Health Choice, and both Sinemet CR (50/200) and Requip (2 > mg.) were being supplied to me for five dollars for a two months supply by > mail or seven dollars for one month's supply at the pharmacy. > > Then it happened: The pharmacies were closed, and we were told to buy our > meds through Express Scripts, if by mail, or at a local grocery's pharmacy, > if we preferred. I recently went to my ND, got two new prescriptions and > sent them in to Express Scripts to be filled. They filled the Sinemet > prescription, but the Requip prescription came back with a form letter that > read: > > "We regret that we are unable to fill your prescription for Requip. The > medication is not considered a Maintenance Drug as defined in your health > plan and is therefore not eligible for your health plan's mail order > benefits. You should obtain the medication from your local retail plan > pharmacy." > > In other words, they explained, it is no longer formulary, and my benefit > is no longer a small copay but rather, I was told, a 50% discount (off of > what?). > > And that upset me for a number of reasons. First, how is Requip not a > maintenance drug? Second, should an HMO be able to reclassify a drug as > non-formulary in a unilateral action? And third, what does this ultimately > mean for prescription drug coverage by Medicare? > > The ramifications of actions like this could greatly affect the quality of > health care in our system. I would be most curious to learn whether or > not others have had similar experiences, what they have done about it, and > what effect it has had. > > Art >