Insurance for Prescription Drugs Only

December 19, 2016 5:12 PM

Is there such a thing as an insurance plan that covers just a formulary of prescription drugs?

I am dually insured through Kaiser and Blue Shield in Southern California. I'd like to nix the Blue Shield plan due to cost, but there's certain medications I've been prescribed that aren't on Kaiser's formulary, meaning, I think, that I would have to pay full price on them. The meds in question are Rexulti and Lyrica, both of which run close to $1K for a month's supply without insurance.

I'm wondering: is there such a thing as an insurance plan that only covers meds? I'm asking because that would mean I could keep just Kaiser and still have access to these meds that have helped me a ton.

Thanks so much!

posted by lilies.lilies to Health & Fitness (10 answers total)

I apologize for the non-answer, but have you tried to get Kaiser to cover the prescriptions yet? My understanding is that Kaiser will pay for non-formulary medication in some circumstances - you need to have a Kaiser doc prescribe them and basically tell Kaiser that you need them, and then it needs to be approved by some internal body. I assume there is an appeals process as well.

While I'm a little fuzzy on the details, I do know that I needed a medication that wasn't on Kaiser's formulary (also SoCal). I first saw a nurse practitioner who said there was no way for me to have it covered by insurance; I later switched to a doctor who had never prescribed it at Kaiser before, but she tried it anyway and it went through - I believe it was at my normal copay.

(Sorry if you've already tried this!)
posted by insectosaurus at 5:20 PM on December 19, 2016 [3 favorites]

Walgreens' "Prescription Savings Club" estimates 30x100mg Lyrica at ~$150/month. Your dosage needs may be different, and $150 ain't cheap, but it's better than $1K. (No results for Rexulti/brexpiprazole)
posted by mumkin at 5:45 PM on December 19, 2016

Sorry for another non answer. I came into the Kaiser system taking a medication that was not on their formulary. They covered it without any issue. My med is old and generic so that might have been in my favor.
posted by cairnoflore at 6:10 PM on December 19, 2016

If you can't get Kaiser to cover the drugs, I'd look into the chain pharmacies. Every pharmacy chain has a prescription "club" like mumkin mentioned, and you can look up online what the costs are for the meds that are covered. I'd weigh that against the cost of Blue Shield's premiums and see which makes more sense.
posted by radioamy at 6:26 PM on December 19, 2016

I just had to deal with this today, clearly YMMV based on your plan details, but just because they don't carry it just means they don't keep it in their pharmacies. They'll order it for you, and you'll pay on it basically the same way you do everything else.
posted by furnace.heart at 6:58 PM on December 19, 2016

It may be worth asking your Kaiser prescribing doctor to reach out to the patient assistance programs (or their local pharma rep) to ask what the options might be, because the pharmaceutical company might be able to put you on a discounted program directly.
posted by lazuli at 9:25 PM on December 19, 2016

Best answer: I doubt you can find the type of plan you're looking for.

Any insurance plan that tried to cover only prescriptions would probably run afoul of the minimum coverage standards of Obamacare and therefore be subject to the astronomical per diem penalties for that. Plus, only people in your situation would sign up for such a plan, so it would basically be a high-risk pool, which insurance companies don't do unless the state forces them to, and even then, the state heavily subsidizes the pool.

For practical solutions, I agree 100% with the other commenters and have had such methods work in the past. Good luck!
posted by radicalawyer at 6:54 AM on December 20, 2016

Generally, insurance plans will cover non-formulary medications (at a higher co-payment, of course) if your doctor contacts them and can show that other meds in-formulary have been tried and have not worked as needed. Basically, the insurer wants to see that you've tried everything else before they'll approve a non-formulary med. The co-pay will still be really high, but not as high as you paying full cost.

But, the drug manufacturers may have assistance programs that can help pay all or part of your high co-pay. Your doc may hve info on the programs and/or the manufacturers website will.
posted by Thorzdad at 6:54 AM on December 20, 2016 [2 favorites]

Adding to what Thorzdad said above, what you'll want to do is get your healthcare provider to do a prior authorization with Kaiser (wiki*) for the non-formulary drugs.
posted by ndfine at 8:55 AM on December 21, 2016 [1 favorite]

Also, you might check for some other pharmacy benefit managers beyond the chain store discount cards. I had luck with GoodRx finding better prescription prices. I'm in the pharmacy data business, but I'm not associated with them.
posted by ndfine at 9:00 AM on December 21, 2016