Can my employer provided pharmacy management company legally refuse to cover my medicine?
Question Details: At the first of the year, my employer provided health insurance pharmacy manager notified me that they were removing my medication from the formulary for this year. I have been taking the name brand medication for years now. Recently, I took a 30 day round of the generic they wanted to switch me to. It did not work anywhere close to being as good as the name brand, which is why the doctor put me on the name brand to begin with. A few weeks later, I am still trying to get over the consequences of taking the generic as opposed to the name brand. To date, the doctor has submitted 2 prior authorizations, both reviewed and denied. Then, the reviews were escalated to an appeal, also denied. The reason, not meeting medical criteria for the plan, which usually translates to "not medically necessary". I am in extreme pain without the name brand, unable to function quality of life, and being without it will greatly impact my ability to to my job. Is this legal or discrimination? If legal, why are they allowed to get away with this?
Yes, they may refuse to cover your medicine: the law does not mandate insurers (or their pharmacy managers) to cover all medications or drugs, if such does not meet their legitimate criteria (e.g. not medically necessary) or is outside the bounds of the insurance policy. The law, as a matter of social policy, also encourages the use of generics, to control our nation's spiraling health care costs, and so as a general matter, encouring the use of generics through insurance is line with our countrys goals and interests. If you believe they are violating the terms of their policy, which is a contract, you could sue them for breach of contract to force them to pay for what they should, but if the denial is in compliance with policy terms, they have the right to do this.