Re: HMO's & medications

[Guest guest]

Gang,

Different HMO's vary in their policies on medications, some are better than

others. But

basically, they are in the business of cost control. They will have a " list " of

approved

medications, (called a formulary) that is mostly generic low cost (older) stuff.

I have read

that some of them are going to a three tiered approach for meds, where the

co-pay is a lot more

for the new expensive drugs. I also read an article about many of them not

allowing the new

Parkinson's drugs (such as Miraprex) to be on their formulary, since the old

one's work fine and

are so much cheaper. I worked in a hospital setting for many years and also

spent one year (15

years ago) working for a new HMO. I have seen first hand the frustrations and

difficulties HMO

members have from the hospital and emergency room perspective. Medications are

the fastest

growing part of the HMO costs, and they really are trying to control them.

I am blessed in that my husband's company has the old traditional health

insurance coverage,

which we were able to take with us into retirement. Otherwise, I am sure my

sleep study and

probably my MRI would have never been approved. Again, one must take control of

their health,

learn the rules, and then fight (if necessary) to get what they need. There is

a lot going on

right now in state legislatures to reign in over zealous HMO's. I do want to

add that if you

have a good primary care physician and a good (usually not for profit) HMO you

can get wonderful

care at a very reasonable price.

Jo from Mo, on my health care soap box.

Lynne Gessner wrote:

> I saw a letter where the person said he didn't know if the HMO

> would cover his Mirapex medication. I don't recall where I heard it (could

> be on this support group) but I heard that HMO's don't recognize RLS as a

> " disease " or " problem " , but if your doctor indicates that the medication is

> for " sleep deprivation " or a " sleep disorder " there is a better chance that

> the HMO pharmacy will okay it.

>

>