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> They also don’t “trump” a doctor’s judgment, they simply state whether or not the claim for medicine is covered under the plan rules. I think it’s incorrect
by erentz 7y ago
> They also don’t “trump” a doctor’s judgment, they simply state whether or not the claim for medicine is covered under the plan rules.
I think it’s incorrect to say they don’t trump the prescribing doctors judgement just because they have a company policy they’re following. They also have the ability to override the policy. This means they are making a decision and when they default to what the policy says, if that goes against the doctors judgement then that is a decision they made to trump that doctors judgement.
This kind of “just following orders” logic is used a lot by people who want to absolve themselves of the responsibilities of their choices.
- lotsofpulp 7y ago>They also have the ability to override the policy. From my understanding, they do not. At least not outside of a certain margin of error, since the payer (for example a state government or employer) would then blame the PBM for approving payment something it wasn't supposed to approve payment for, and hence seek reimbursement from the PBM or cancel its contract and go with another PBM.
- erentz 7y agoI’ve had specialty medicine approved that very clearly goes against policy at different phases of the review process (including immediately) on different insurance plans. So they do seem to me to have this power.
- lotsofpulp 7y agoI can't answer for why they would violate the policies they are supposed to be enforcing, but I do no know PBMs get audited by governments and penalized for improperly approving medications for Medicaid recipients.
- darkerside 7y agoWhat do you think is happening during the appeals process?
- lotsofpulp 7y agoThey're not overriding policies set forth in the formulary during appeals process. Obviously, this problem space is hard to define so there is room for error and difference in judgement by people approving and denying, so an appeals serves the same purpose as it does in the court system, to get a second or third look on a decision to see if it was correct or not.