One can always pay cash for it, but insurance companies have been legally
able to do this for years in the U.S.

On Tue, 20 Feb 2007 13:17:08 -0800, zimsawyer wrote:

As the other reply stated, you can pay cash. The insurance company is not
holding the rx hostage; they are simply withholding coverage according to
the details outlined in the coverage plan. You are able to get the entire
prescription at any time you wish.

Insurance companys aren't second-guessing medical professionals, they
employ many medical professionals (Doctors, Pharmacists, et al) who are
involved in deciding formulary issues. It is not as if they are clueless
and only look at the bottom line (although that is definitely their
primary concern).

They are doing nothing illegal, nor even unethical in my opinion in this
case. Lexapro (escitalopram) is nothing but a _supposedly_ improved
version of Celexa (citalopram) that the company came out with when they
lost their patent coverage on Celexa. Just as the patent was to expire,
the manufacturer comes out and says "look here, we know the S enantiomer
of citalopram is more biologically active, and not consuming the R
enantiomer _may_ result in less side-effects, so we developed a way to
separate the two." (A 20mg tab of Celexa contians ~10mg of Lexapro, and
~10mg of the R enantiomer).

Funny how the manufacturer wasn't concerned about these issues while
their Celexa patent was in effect, or even before they marketed Celexa. Or
maybe it is just coincidence that they were able to figure this out just
as their patent expired.

If he has a compelling reason for using Lexapro rather than generic
Celexa (citalopram) I hope he is able to get the drug covered. If not, I
see no problem with needing to at least try a more cost-effective generic
(or formulary brand, if there is one) first.

Best wishes.

p.s. I had to laugh. I went to celexa.com, and the very first thing you
are faced with is a giant banner for Lexapro (understandable from a
business sense). And if you click through to the Celexa information, they
push Lexapro and even include a statement that 47% of people who did not
respond to Celexa did better on Lexapro. Neither of the references for
this claim are from peer-reviewed journals. One was a poster session
(meaning that the manufacturer gave some Dr a free vacation to Puerto
Rico and/or a "consulting fee" to spout the company line at a
convention) and the second reference was "Data on file". Would that
file be located in the Marketing department? Talk about ethics...

Insurance companies are "not paying" for this or that more and more lately!

Any excuse to not pay seems to be the rule.

I have dental insurance which says just about everything I have done is not
necessary! Then my dentist battles with them for a few months and they
eventually pay.

Then there are some older drugs which are only approved by the FDA for
certain things. But since they came out, these drugs have been found to help
with many other things. Insurance companies will be quick to deny paying
because it is not for an FDA approved use! Well everybody and their brother
knows these drugs are very good for these other uses. And the drug
manufacturer will not get additional FDA approval for the new uses as their
patent has expired. No point in spending the $$$.

I have a friend who works in a doctors office. For one patient the insurance
company paid for an x-ray, but refused to pay for having the x-ray looked at
by a radiologist! In another case there is only one hospital in the state
which could perform a certain procedure. The insurance company said the "out
of area" treatment was not necessary, that the patient could have the
procedure done "in area". They are currently battling with the insurance
company to get them to understand that this hospital is the ONLY facility in
the state which can perform this procedure.

I can go on and on....

The insurance companies employ doctors and pharmacists to develop their
formulary.  The point of a formulary is to control costs, of course,
without sacrificing therapeutic benefit.  But if someone can decide, at
will and with no additional cost, that they'd just prefer, say, name
brand Synthroid over generic levothyroxine, every subscriber to the plan
pays the additional cost, because it can't be operated at a loss or it
will soon go away.  Since the cost of health care has been rising faster
than incomes for a long time, about half of that being prescription
drugs, and 15% and rising of the population is uninsured because they
can't afford it, I think it would be unethical to NOT look at the bottom
line.  If you can't afford health insurance, that can have a serious
impact on quality of life!

Some plans will pay for brand drugs, but require the patient to make up
the difference in cost.  Some patients, when they realize what the
difference in cost is, decide to give the generic "one more try", and
hey, I guess it does work, after all.

The insurance companies typically won't deny coverage for a drug that
you need.  But sometimes they first want it proven that you need it.  If
the insurance company feels that there are other drugs on the market
that would help him just as well and be more cost efficient, then maybe
there really are other drugs on the market that would help him just as
well and be more cost efficient!  (Do you have a reason for thinking
they're wrong?)  If those don't work, the doctor can send them a prior
authorization, which has more detail than a prescription and explains
what has already been tried and why the other drugs are needed.

Doctors don't always know what will be covered and what won't, so they
might just pick a drug and write a script.  Get some communication
going.  Find out what's on the formulary, talk to the doctor about it
and see if he would be comfortable prescribing it.  And be willing to
try it.  If there's some reason it won't work, then ask the doctor to do
the paperwork to approve the non-formulary drug.

And if you need to, consider switching insurance plans.