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November 12, 2011 2:10 PM

[Massachusetts filter] Anyone have any experience with Tufts medical plan and getting Wellbutrin XL (or any other brand-name psychiatric meds with generic equivalents) covered by them?

Just started a new job. New job has Tufts health insurance. Looking at their paperwork, they seem to be really, really aggressive about not covering brand-name medications when there's a generic equivalent and the information about their prior-authorization process is murky at best. I reached out to them to ask more, but I just got the same party-line they've got all over their documentation about my doctor needing to prove it's a "Medical Necessity" without actually explaining what that entails. I asked my doctor's admin, and while she said she had the paperwork to show that I've tried a variety of other meds, she couldn't guarantee they'd cover it either (but didn't have a feeling for the likelihood, either).

I'm currently paying out the nose for HPHC through COBRA. HPHC's coverage of my meds just seemed to require a simple token confirmation from my doc...and I don't think I've ever been on a plan before that so emphasized their unwillingness to cover a lot of drugs or required the You-must-try-X-Y-and-Z-first hoops Tufts says they do. I'm terrified of switching to Tufts, losing my COBRA eligibility, and then being denied coverage and losing my meds - the Wellbutrin generics didn't work for me the last time I tried them (4 years ago) and I don't feel like playing brain chemical roulette again, especially not while I'm just starting a new job.

Now I'm looking for either anecdotes of anyone who's been approved (or rejected) for brand-name psychiatric meds with Tufts, or any other ideas for how I might confirm getting my meds so I can settle once and for all whether I can switch? Thanks!

Throwaway email: [e-mail]

posted by anonymous to Health & Fitness (4 answers total)

Hi -- I have Tufts. I have no experience with Wellbutrin XL specifically, but I did recently get coverage for Celebrex, which is normally not covered. I didn't have to really go through any hoops, and the process was very fast. I had tried another of the same drug class (another NSAID) and my condition had been intractable for ~3 months, for reference. I suggested to my md that I try the Celebrex, she made the request to the insurance and I had the pills within two days.

I am totally guessing here, but I'm thinking that the requirement may end up being that you try another antidepressant (the generic form of wellbutrin even), and once your doctor confirms that it doesn't work, and that wellbutrin xl seems like a good next attempt, it will go through. a supporting factor here is that you have been under treatment with wellbutrin xl already; perhaps even that, along iwth your doctor's submission of your previous history (non-success fo the generic) would be enough for the insurance company, without trying something else. but this is really my total guess. my doctors have also been really hesitant to say, 'yes, this always goes through', but i haven't had problems so far.

i feel for you being under this indecision about whether to switch coverage. hopefully, someone else has a more related experience with Tufts.
posted by Tandem Affinity at 3:11 PM on November 12, 2011

Get your docs fax number and call member services. Ask them to fax a prior auth form and an FDA medwatch form for a DAW override. If your benefits don't allow for a DAW override ask if "copayment exception".

Per your benefits if no luck, raise concerns with HR. They do have the ability to get an override for you.
posted by Bun Surnt at 6:14 PM on November 12, 2011

*** imformation was for Tufts. HPHC's DAW1 is nice.
posted by Bun Surnt at 6:17 PM on November 12, 2011

The only thing tufts gave me a problem with was lipitor. They had no problem covering a pre-existing prescription for wellbutrin.
posted by rmd1023 at 5:30 PM on November 13, 2011