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Today's single payer post: Who wrote your last Rx?

DCblogger's picture

Some NY HMOs Impose Consumer Drug Restrictions To Increase Profits

A report just released this weekend by state Senator Jeffrey Klein (Democrat) reveals that some New York state HMOs restrict patient access to single source drugs or brand name medications for specific ailments that do not have lower cost generic versions. The report includes a survey of the 15 HMOs with drug plans in New York state, including Aetna, Oxford Health Plans, Cigna, Health Insurance Plan of New York, Group Health Associates, and HealthNet of New York and was conducted to determine how and if companies restrict prescriptions to 20 of the most common single-source drugs. The results point to HMOs setting these restrictions to increase their bottom lines and enhance profits.

The survey confirmed that a number of restrictions are placed on consumers, such as a “medical exception,” imposing quantity limits, and a “step therapy” rule. A medical exception is when a patient and physician must obtain prior permission from the insurer so that a patient can receive coverage for a prescribed medication. Medical exceptions are granted at the discretion of the insurance company. Step therapy forces patients to try one or more other medications before seeking approval for a prescribed drug. “It’s a dangerous situation,” Klein said. “Clearly, when a doctor prescribes a specific medication for a patient and they know that drugs works for a patient, they shouldn’t be forced to use a generic drug or cheaper alternative that may not work,” he added.

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Submitted by lambert on

It's a machine for extracting the maximum amount of profit from suffering flesh.

And if the requisite amount of suffering is not present, it will be created. (See Diet, American. See also Marketing, Food.)

[x] Any (D) in the general. [ ] ?????. [ ] Any mullah-sucking billionaire-teabagging torture-loving pus-encrusted spawn of Cthulhu, bless his (R) heart.

Iphie's picture
Submitted by Iphie on

I think that it's a system designed to make it so difficult to get the care you need that you eventually give up and stop asking for it. I have HIP (which recently went from being non-profit to for-profit) which I hate, but they require prior authorization for every name-brand prescription -- even those medications for which there is no substitute. I don't know if that's common, or even acknowledged, but the pharmacist confirmed for me that that is the case. Basically, they have created another layer of bureaucracy that the patient, doctor and pharmacy all have to go through.

One way to minimize the hassle is to get your doctor to put lots of refills on the original prescription. Most doctors don't like to do more than a couple refills, but if they're willing to do it, multiple refills on the same scrip only requires one PA. This is, of course, only relevant if you have medication that you take regularly. I'm learning all sorts of ways to get around the BS.

DCblogger's picture
Submitted by DCblogger on

it does not speak well of us that we have put up with it.

Salmo's picture
Submitted by Salmo on

I have a brother and sister-in-law who practice medicine in New York. I remember a conversation we had a little over a year ago in which my brother talked in general terms about a patient he had treated as a medical exception to the spread sheet medicine he was supposed to follow. He was expecting discipline because he had already used up the exceptions allocation for the previous six months. He was angry and defiant. I do not know what eventually came of it, and I certainly have no patient specific information.