Brand Name Drugs

[its2much]

My kids are covered under a prescription plan with MEDCO, now Express Scripts, through their father. One kid has been prescribed a brand name drug after the generic version has not been effective.
I can't get much information regarding the plan but am wondering if it is possible to appeal to the insurance plan for coverage for the brand name. They have rejected claims to pay for the drug since it's not a generic. The cost for this one drug is $550 per month.

[hunterd]

My kids are covered under a prescription plan with MEDCO, now Express Scripts, through their father. One kid has been prescribed a brand name drug after the generic version has not been effective.
I can't get much information regarding the plan but am wondering if it is possible to appeal to the insurance plan for coverage for the brand name. They have rejected claims to pay for the drug since it's not a generic. The cost for this one drug is $550 per month.

You can appeal and you should appeal. Now that I have said that, I don't think the brand name will work either. The brand name and the generic should have the same active ingredients.

You should get whatever information you want by calling the 800 number on the back of the insurance card ( at least that's where most of them are). The people that work at the insurance company are usually helpful. one thing to keep in mind when you call is to not be irate or ignorant ( I have found this to be helpful personally).

[its2much]

There recently was a study

that the generic is not as effective as the brand name - that's why the doctor prescribed it because the generic wasn't working.

[ghostgirl]

Oh, good, I have experience with this question.

Yes, you can get it covered but the doctor needs to justify to the insurance company why the more costly med is require. If the doc can make it a "medically necessary" prescription to be filled in non-generic form then it should be fine. Your doc has to do the paperwork though.

Hunterd also made a good point. Should you have trouble, call the insurance company directly and see what they require to get the med to go through.

Best of luck.

[onlyairfare]

Generic drugs are not necessarily exactly the same as the brand name equivalent; I think they are allowed to be as much as 20% different in content either way, higher or lower. They may also have different dyes and binders. For most medications this does not make a big difference, but for a few medications and for an individual patient, it is possible that the brand name actually does work better for you, even if the trials and the FDA have declared them equivalent.

You should definitely appeal the denial and be very specific about why the brand name is better for you, and why that will work better in your case than the generic. Otherwise the insurer will just say "They are the same, so get the cheaper one."