Is the offered health insurance formulary a binding contract?

[Robmoo]

What is the name of your state (only U.S. law)? Texas

My employer has Prascion, a facial wash I use for my Rosacea on the medication formulary. According to our pharmacy Maxor refuses to cover Prascion because it is among the FDA disapproved medications. When I signed up for benefits for this year it was on the list. Is my employer obligated to cover this medication as spelled out in the benefit package? If they refuse to cover it do I have a case under the Texas Deceptive Trade Practices Act either against my employer or Maxor? I'd prefer not to sue my employer and "poison the well" so to speak. Prascion has kept my Rosacea under control for over a decade and I want to keep it that way.


Thank you!

Robert

 

[FlyingRon]

You've lost me. The FDA disproved Prascion how?

Almost certainly your terms of insurance coverage allow them to change the formulary list. In some cases, you can appeal to the insurer (with your doctor's support) as to why this drug is better necessary for you rather than whatever they would want off the preferred list (or an OTC substitute).

 

[cbg]

No and no. Formularies can and do change; they generally change every year; the fact that it was on the formulary initially does not create a contractual guarantee that it will be on the formulary forever.

 

[ecmst12]

That product can't be legally prescribed or sold in the US. Why would you think there was even a chance that your insurance would cover it?

 

[Robmoo]

That product can't be legally prescribed or sold in the US. Why would you think there was even a chance that your insurance would cover it?

Because they have been for the last 10 years.

Apparently the FDA has been reviewing older medication to see if they meet modern standards for proof of efficacy. If the medication doesn't they add it to a "disapproved" list. Roscacea sufferers have a higher than normal bacteria count. The anti-bacterial facial cleanser helps with this and reduces the symptoms. Evidently when the medication was initially brought to market and approved the standard of proof was lower than current standards.

 

[Proserpina]

Because they have been for the last 10 years.

Apparently the FDA has been reviewing older medication to see if they meet modern standards for proof of efficacy. If the medication doesn't they add it to a "disapproved" list. Roscacea sufferers have a higher than normal bacteria count. The anti-bacterial facial cleanser helps with this and reduces the symptoms. Evidently when the medication was initially brought to market and approved the standard of proof was lower than current standards.

A medication/device is either FDA-approved, or it's not.

Read: http://www.fda.gov/AboutFDA/Transparency/Basics/ucm213030.htm

 

[Dave1952]

Have your physician prescribe a new product for your rosacea. One that's listed in the current formulary.

 

[cbg]

^^^Certainly the simplest answer to the problem.