28 ms·

After ACA there are no lifetime maximums. If it’s an FDA approved treatment which he is eligible for (e.g. there are not other first line treatments which shoul

by zaroth 7y ago

After ACA there are no lifetime maximums. If it’s an FDA approved treatment which he is eligible for (e.g. there are not other first line treatments which should be tried first) then AFAIK an insurance company cannot simply refuse to pay. Another option is to move to a Medicare expansion state and stop working, which will allow you to immediately qualify for free health care with generally some of the best coverage you can get.

refurb 7y ago
Insurance companies are free to not cover an FDA approved product. CVS publishes a list every year, although they tend to either be the branded drug when a generic is available or a drug where there are as effective, but cheaper products are available. It’s a cost versus benefit analysis and no different than what you see in single payer systems. I will say from experience that oncology is one therapeutic area where payers wield much less control. Insurers don't like bad press and denying cancer drugs is a great way to end up in the NY Times. That said, if a drug is regarded as "experimental" (either the FDA hasn't approved it for that type of cancer OR there is limited data to suggest it works) they will say "no". https://www.caremark.com/portal/asset/Formulary_Exclusion_Drug_List.pdf https://www.caremark.com/portal/asset/Formulary_Exclusion_Dr...
- zaroth 7y ago
  Insurance companies certainly can have formularies. I noticed that there aren't any drugs on the excluded list that don't have alternatives listed. When we change insurance plans my kids have to change the brand name of insulin they get. Humolog, Admelog, etc. But the insurance company can't decide that they won't pay for fast-acting and slow-acting insulin. And if there is a medical reason a doctor will sign off on that indicates a specific brand is required, I believe that you can generally get even excluded medicines covered. Can insurance companies refuse to cover an FDA approved drug that doesn't have a reasonable substitute? OP discussed treatment for leukemia. An ACA plan should cover approved treatments for leukemia, but it might not cover, e.g. the latest CAR-T treatment if it's still in Phase 3. You would need to get into the study, in which case treatment would be free.
thawaway1837 7y ago
Just to be clear, you mean that the insurance company is not allowed to set a maximum lifetime (or annual, for that matter) limit beyond which they will stop paying expenses, correct? P
- zaroth 7y ago
  Under an ACA approved plan, that is correct.

by zaroth 7y ago

refurb 7y ago

Insurance companies are free to not cover an FDA approved product. CVS publishes a list every year, although they tend to either be the branded drug when a generic is available or a drug where there are as effective, but cheaper products are available. It’s a cost versus benefit analysis and no different than what you see in single payer systems. I will say from experience that oncology is one therapeutic area where payers wield much less control. Insurers don't like bad press and denying cancer drugs is a great way to end up in the NY Times. That said, if a drug is regarded as "experimental" (either the FDA hasn't approved it for that type of cancer OR there is limited data to suggest it works) they will say "no". https://www.caremark.com/portal/asset/Formulary_Exclusion_Drug_List.pdf https://www.caremark.com/portal/asset/Formulary_Exclusion_Dr...

zaroth 7y ago
Insurance companies certainly can have formularies. I noticed that there aren't any drugs on the excluded list that don't have alternatives listed. When we change insurance plans my kids have to change the brand name of insulin they get. Humolog, Admelog, etc. But the insurance company can't decide that they won't pay for fast-acting and slow-acting insulin. And if there is a medical reason a doctor will sign off on that indicates a specific brand is required, I believe that you can generally get even excluded medicines covered. Can insurance companies refuse to cover an FDA approved drug that doesn't have a reasonable substitute? OP discussed treatment for leukemia. An ACA plan should cover approved treatments for leukemia, but it might not cover, e.g. the latest CAR-T treatment if it's still in Phase 3. You would need to get into the study, in which case treatment would be free.

thawaway1837 7y ago

Just to be clear, you mean that the insurance company is not allowed to set a maximum lifetime (or annual, for that matter) limit beyond which they will stop paying expenses, correct? P

zaroth 7y ago
Under an ACA approved plan, that is correct.