[vostok]

Assuming this is post-Obamacare, do you know why your insurance didn't cover it? I had this simplified model that insurance covers everything once you hit maximum out of pocket and I'd love to learn how that model breaks down in practice.

[maxerickson]

Your insurance has a pharmacy benefit manager (PBM) that has a formulary (the list of drugs they cover). Multiple insurers might use the same PBM. New drugs aren't automatically covered, as they haven't necessarily made the calculation that the cost of it justifies using it versus the alternatives.

It's intentionally complicated in order to fracture responsibility, avoid paying out claims and extract payment from publicly funded insurers.

[howard941]

If the medication is on the formulary the max out of pocket is usually somewhere around $12K. It's not capped if it's not on the formulary. And fancy new drugs are often off the list.

[zdragnar]

My insurance company would have, but wanted me to try an older, cheaper drug first. Since the older drugs have a much more dangerous list of potential side effects, including lymphoma and skin cancer, and since the eli lily foundation would have covered it regardless, it was a no-brainer.

The co-pays on tier 3 (i.e. super spendy specialty drugs) are crazy anyway, so insurance covering it wouldn't have really changed the affordability aspect one way or the other.

[lotsofpulp]

The insurer is supposed to cover everything, as long as it is justified by the prevailing evidence and there is no alternative treatment.

However, you may have to fight for it.

https://www.healthcare.gov/appeal-insurance-company-decision...

[zdragnar]

My insurer wanted me to try a different, older biologic first. My dermatologist recommended going with Taltz instead because

- the eli lily foundation pays for it anyway

- the older biologics have far more serious side effects profiles

Given that, it was kindof a no-brainer. I would have needed to go through the foundation anyway, since the co-pays on these drugs are insane regardless.