Step/Tier Medication Formularies as an Access Barrier in treatment

Another important aspect of treatment is your Medication Formulary. These are lists of what are considered “covered” medications by your insurance. These vary depending on your insurer and benefit plan. These are available to you either through direct discussion with a pharmacy representative (from your insurance company), or on the website of your insurer (once you log into the online system.)

Once you have located your formulary (in either print or online format – your preference), your will notice that there are “steps” or “tiers”. These are categories of medications. The categories generally relate to the cost to the insurance carrier for providing pharmacy coverage for that identified medication to those who are covered members (i.e. you.) You should review your formulary with your physician, so that medications being prescribed can be considered based upon your coverage/benefit.

Depending on your insurance plan and/or benefit plan, you may be required to go through the “step” or “tier” process. To put this into easy language, if the medication your physician is prescribing is considered a Step or Tier 4 medication – you may be required to have utilized a similar medication and demonstrated it to be medically non-beneficial. Therefore, you must first utilize the most similar medication to that which your doctor would prescribe in Step or Tier 1 -3 before being able to have a Step or Tier 4 medication covered.

If you decide that you will not accept the medication from the prior Step or Tiers, then you have a few options.

1. Discuss the insurance recommended medication (from the prior steps/tiers) with your doctor – perhaps he/she feels this would be as efficacious as the one initially discussed.
2. If your physician still feels that you should utilize the specific medication he/she is recommending, inquire whether there is a generic available for the medication. With this information, then you should contact your insurance plan – speak with a pharmacy representative – and find out what the cost will be to you for that medication as it presently stands. Additionally, during that call confirm if there is a generic, and what the cost will be.
3. If your physician feels that the prescribed medication is the only medically necessary and appropriate option based upon his/her medical assessment as your physician, then you and your physician can file a request with the pharmacy department to utilize – and have covered – a medication that is out of step or out of tier. There will be a form for you and your physician to complete. The form is usually completed by the Billing Office or Nurse Navigator at your physician’s office – in conjunction with the physician. (They should be familiar with this process.)
4. If, after you and your physician have submitted the request for covering a medication that is out of step or out of tier, has been denied. You should utilize your Appeal Rights. It is recommended that you speak with a nurse case manager or pharmacy case manager through your insurance to inquire about specific steps for a pharmacy appeal process. Here again, there is usually a portion for you – as the patient and insured person – to complete, and a portion for your physician to complete.

Regardless of insurance carrier or benefit package, generally there are many levels of appeal available. Usually, the first is where you and your physician submit documentation to support why this specific medication – and no other generic or similar – is the only medically necessary option for your medically appropriate treatment. This is then reviewed by a physician from your insurance company for a medically necessary determination to be made. If the request is denied at this level, most insurance companies have a second level appeal – where a different physician (i.e. not the same physician who previously denied under your first level appeal) must speak doctor-to-doctor live. This is usually arranged by your insurance company directly with your physician. During this call, your physician will make the clinical case for why you need this specific medication at this specific time given your particular medical presentation. If your second level appeal is denied, you and your physician can request an external appeal. This appeal goes to an outside company who will then have what is sometimes called a “Fair Trial Hearing.” The purpose is to determine whether the insurance company provided appropriate medical coverage to you (the insured), and whether the physician’s request is medically appropriate – and therefore the original denial would need to be overturned – ultimately allowing you to receive the medication ordered as a covered medication at the benefit plan appropriate rate for that step or tier.

During the appeals process, no matter which level you are on, it is important to have a Nurse Navigator or a Peer Navigator through your insurance. It is also critical to be in direct discussion with your physician, and their support team, for updates on the status of the process. Keep organized and clear records – it is encouraged to keep them in chronological order – and read each and every line. If there are terms or concepts that you are uncertain about, call your insurance and speak with your Nurse Navigator or Case Manager to have them clarify – ask them the same question multiple times if necessary until you are absolutely certain that you understand what your paperwork states.

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