Today's word is "formulary"

[redbird]

Which is current insurance jargon for "we won't pay for the medicine you've been taking, you have to change to something cheaper."

So the friendly pharmacist called my doctor, and instead of Celexa I have something called Lexapro, which is supposed to be as good. I hope so. It will certainly be less convenient: the instructions read that I am to take "1/2 to 1 pill daily".

Comments

[elisem.livejournal.com]

Yeah. "Formulary" seems to equal "the generic."

There are cases in which one can get an exception. Generally, they involve trying the generic; if/when it does not perform adequately compared to the proprietary drug, one's doctor fills out a form stating that the patient in question ought to be given the name brand kind. The form goes to the insurance company, and the insurance company then informs the patient whether the exception has been granted or denied.

I've got a letter here which reads, in part:

"Your physician's Brand copay override request for Cylert has been reviewed by [BigInsuranceCompany] and [TheirBigInsuranceCompanyFriend].

According to the documentation provided by your physician the following outcome has been determined:

Granted

GRANTED COVERAGE EFFECTIVE [date] - [date] FOR [length of time] FOR THE BRAND PRODUCT AT THE FORMULARY COPAY LEVEL."

Which is a useful thing. The formulary type gave me extremely unpleasant results, and the brand name stuff works just fine.

[carbonel]

How odd. My insurance company won't pay for Lexapro (which is actually the newer, "better" formulation unless I try Celexa first and have problems with it. I seem to be tolerating the Celexa just fine barring minor queasiness, so it doesn't matter.

The doctor told me that Celexa is going to be going generic in the next year or two (at which point my co-pay will halve, which is nice), but Lexapro is still quite new.

Formulary

[webbob.livejournal.com]

More seriously, "formulary" means "on the list of drugs we've agreed can be supplied at a particular co-payment because they're cheap enough to meet our business plan requirements."

In this case, you should definitely speak to the prescribing doctor because Lexapro/escitalopram (http://www.nlm.nih.gov/medlineplus/druginfo/medmaster/a603005.html) is chemically different from Celexa/citalopram (http://www.nlm.nih.gov/medlineplus/druginfo/medmaster/a699001.html) and not a simple generic substitution like the ones elisem mentions. That definitely is a potential basis for a waiver, if the prescribing doctor has a rational distrust of the alternative substance, which is probably a follow-up drug intended to replace Celexa when its patent expires. In fact, as carbonel notes, it's an odd substitution for an insurance company to make, with Celexa dropping in price in the near future.

(Don't know if those links will work, they're references to the drug information database (http://www.nlm.nih.gov/medlineplus/druginformation.html) at the NIH MedlinePlus site.)

Re: Formulary

[redbird]

I think that Lexapro may be the one he was considering switching me to on my last visit, before I said "let's hold off until I sort out the insurance". I'll be starting the Lexapro tomorrow, and I'll see how it works.

[red-queen.livejournal.com]

I find this to be one of the most infuriating and damned near immoral aspects of Managed Care (please pronounce that dripping with irony). Psych meds *especially* can be weird in that no-one's quite sure how they work. It's cruel enough when one's meds "wear off" and one has to go back to trying different ones in hopes of finding another effective anti-depressant (never mind the combinatorical problem when you need more than one!). Having to change meds when *they still work* and even slightly risk getting depressed (or whatever) because an HMO's rules and bean-counting dictate the policy...! A mind IS a terrible thing to waste. (Not that your "underlying condition" (she said, euphemistically) is completely disabling, but sheesh, why waste any of the available (very high quality) marbles when you don't have to??)

I don't disagree with the health care industry's need to control unnecessary expenses (i.e., doctors writing scripts for the most heavily-advertised still-patented drug rather than checking to see if there's a less-expensive alternative). I just bristle that need turns into a set of rules that are enforced regardless of context. We all know how bad the American health care system is; I find it terrifying and immoral that so many vulnerable people (esp. seniors and the chronically ill poor) cannot get basic care, and cannot get their maintenance medications, without a lot of angst, advocacy, and fighting. Those who are not willing or able to fight... die or live a diminished life.