I get it. Most members in HMO plans love affordable premiums but can’t stand the limited provider network. No one loves everything about everything. And yet, limited providers aren’t the only thing members dislike about HMO plans. Often, you can add the drug list (or formulary) to the list.

I see this whenever members leave a PPO plan and come to an HMO plan. A member may be taking a certain medication under a PPO plan (the plan covered it); when the member leaves the PPO for the HMO, however, the member wants to continue taking a certain medication but discovers that the plan won’t cover it. The reason? the medication isn’t on the approved drug list.

How can this member make their new HMO plan work for them and not against them? To answer that question is to also answer how you can make your HMO plan work for you.

We shall answer them both in one response below.

hmo plans have a smaller drug list

One thing that you may not wanna read, though you need to read it, is that HMO plans likely have smaller drug lists than PPO plans. What this means is that it’s not uncommon to find that certain medications (or drugs) aren’t covered by the HMO plan whereas, with the PPO plan, they were covered without trouble. PPO plans often have more money because members pay more for services than they do on HMO plans.

It’s no different than two churches where one church is blossoming with over 30,000 members while the other church has no more than 300 members. You wouldn’t expect the 300-member church to have the paying power of the 30,000-member church, would you? Now, you may be surprised to find that the 300-member church could have the paying power; after all, more members does not necessarily make a church wealthier than another.

It depends on the paying power of the members. You may have 30,000 members in a church, but if they’re all living below poverty level (an unfortunate but true-to-life situation for so many; God bless them), then the 300-member church has more of a fighting chance — especially if they have doctors, lawyers, engineers, and other high-paying careers present in their congregation.

So with that said, PPO and HMO plans aren’t the same. They never will be. They are designed for different preferences. HMO plans are designed around affordability, while PPO plans are designed around flexibility. Affordability and flexibility aren’t the same thing. To have one doesn’t necessarily include the other. And so, if you have a PPO plan but dislike the pricing, HMO plans are preferable but come with limited flexibility. And vice versa.

So when it comes to HMO plans, just like with limited providers, there will be a limited drug list or formulary. That shouldn’t be surprising, considering the nature of HMO plans, but it does tend to shock some.

my drug isn’t on the drug list; what to do in non-formulary situations

Is your drug not on the drug list? If you find yourself in this situation, you have what is called a non-formulary drug (at least with the HMO insurance company you’re with).

Non-formulary drugs are not on the drug list, which means that the plan, in many cases, won’t cover them. Now, your PCP can fill out paperwork for those non-formulary drugs and send it back to the plan (often via fax). However, the doctor will also have to submit medical notes regarding why the plan should approve and cover a medication, not on its drug list. And often, when a med is denied at the pharmacy, there’s a reason. Insurance customer service reps can look up those pharmacy claims and tell you why a medication was denied.

In order to get the medication covered, you can go back to your primary care physician (PCP) or a specialist. However, there is no guarantee that, even with your doctor filling out paperwork, that a non-formulary medication may be covered.

Doctors have so many days to supply notes for the paperwork, and so, it could be at least a 2-week wait before the plan receives the paperwork to render a decision. So with that said, you’re going to have to wait a while for the non-formulary drug to be considered and covered.

If you don’t like the idea of paperwork and waiting for the doctor to send it in and the plan to consider the request, you can always consider requesting alternatives to this non-formulary medication. Ask your insurance company, “are there alternatives to this drug or medication that the insurance plan does have on the list?” It’s a simple question, but it could allow you to find some names of medicines that you can discuss with your doctor.

Make sure to discuss all medication alternatives with your doctor. However, if you try the covered alternatives (after talking with your doctor first, that is) and they work out, you could also find yourself saving lots of money while maintaining your quality of life. And you wouldn’t have to keep going to your doctor about the same paperwork, year after year after year.

Without an alternative, the non-formulary medication will cost the full amount out of pocket. You will owe the full price unless you receive 1) a manufacturer’s discount, often supplied at the pharmacy at the checkout counter or 2) research and discover some sort of discount program like GoodRx, which proves helpful to a number of members with regard to medications. These medication-saving programs can be helpful, but members would have to go this route on their own.

Keep in mind though, just because a medication isn’t on your HMO plan’s drug formulary list, doesn’t mean that Medicare (CMS) doesn’t cover it. There is a difference between “non-formulary” and “CMS Excluded” (CMS stands for “Center for Medicare and Medicaid Services,” if you’re wondering); what isn’t covered by your plan could be covered by Medicare (CMS). Be sure to inquire about whether or not the medication you want is non-formulary, CMS Excluded, or both. If the medication in question is simply non-formulary but not CMS Excluded, it is still approved by Medicare and there may be some form of medication discount programs Medicare provides for it.

medication samples: At the doctor’s office

If you want to take a non-formulary medication, the plan refuses to cover it, and you cannot afford it out of pocket, you can always ask your local doctor’s office for some medication samples. Keep in mind that, if you receive these medication samples because you requested them, you’re taking them at your own risk. However, they may be available at the doctor’s office. Ask your doctor’s office for medication samples.

Before accepting those med samples, it may be a good idea to ask your doctor about the medication itself, whether or not it would be a good fit, and so on. The reason? Med samples are small amounts of actual medications. Just as a bottle of pills can provide some serious side effects, so can medication samples. And so, it couldn’t hurt to ask the doctor if the sample you want to take is safe and effective for you. After all, your health is your life.

making your hmo drug list work for you

HMO plans are crafted with affordability in mind; however, this may seemingly work against you, depending on the medication you want and/or need. And so, in these times, there are a few things at your disposal:

1. Coverage Determinations — in the event that you cannot just go pick up the drug with a prescription, your doctor can always fill out a coverage determination to request that a particular drug, not on the list, can be covered. HMO plans decide on these requests on a case-by-case basis. What this means is that you can’t expect the plan to cover your medication, even if they approved the medication to be covered for someone else. And yet, there’s no harm in getting your doctor to see if you can be approved for it. Just visit with your primary care physician (PCP) or specialist and have them fill out a coverage determination and submit it to the insurance company for approval.
2. Discount Programs — in the event that the plan still won’t approve the medication, but it is not CMS Excluded, there are Medicare discount programs such as GoodRx you can look into for help. “CMS Excluded” is a label used to show that a drug is not Medicare-approved. If the medication is CMS Excluded, then you’re expected to pay full price and are taking it at your own risk should you buy it. If the medication is merely non-formulary, then, while the plan may not cover it, you can still find Medicare discount programs that may help foot the bill. You can always talk to your doctor about Medicare discount programs and see what he or she can do to help.
3. Reimbursement Requests — Additionally, you can always request that the HMO plan reimburse you for all or a portion of the cost. HMO plans allow for what is known as reimbursement requests. Any member is eligible to write the plan and request reimbursement for a particular medication, even if it is non-formulary.
4. Doctoral Research — This last aid for those with HMO Drug Lists is not about an academic research program. However, it is about your primary care physician and specialists that are treating you. When it comes to your health, there may come a time when the PCP (primary care physician) or the specialist needs to research to come up with a more affordable medication that works for you. For example, you may be a patient who needs Eliquis or Xarelto but can’t afford the high sticker price of these medications. In that case, your doctor may need to identify Eliquis and Xarelto as blood thinners and find an alternative blood thinner that is still on the plan’s drug list. When it comes to blood thinners, there are others on HMO drug lists that may be approved and may be far more affordable and save you money.

In the midst of these options, the first thing to do is talk with your doctor. Your doctors are medical experts who will do their best to make sure you’re safe in taking a particular medication. You cannot trust that a drug works best for you because it works well for your neighbor or a friend. The reason? you have a different system than others and you may have allergies or other medical issues that make a proven medication all wrong for you. “One size” does not “fit all,” even in the pharmaceutical world.

But, if your doctor is willing to let you try an alternative, it could prove to save your life — and your wallet.

Even in the midst of a small HMO Drug List, you can still make your plan and the drug list work for you. When life throws you lemons, you can still make lemonade.