Michael asked
Can your insurance company tell the pharmacy and your doctor that a patient is being given too much medicine?
Answer
Yes, an insurance company can dictate what they will cover and pay for, regardless of what your doctor has prescribed. This will be based on their coverage formulary.
While an insurance company can't "tell" you and your doctor what your therapy is, they can choose not to cover certain medications and dosages.
This is controversial issue. While your insurance technically isn't dictating what your medication therapy is, if they choose not to cover what is prescribed, they are in essence doing just that. Most medications are very expensive and it isn't feasible to pay out of pocket ('cash') for them. This is especially true for newer, brand name drugs as well as necessary drugs used in the treatment of diabetes, asthma, infectious disease etc...
It is a fairly common saying that "we live in a managed care world". What they choose to pay (or not pay) for, does in fact dictate therapy for many patients.
Now, what an insurance company covers isn't random. They have published formularies and typically follow published dosing/therapy guidelines. When they see a higher than usual dose of a medication, they may require more information on why you are being prescribed that dose. If you are trying to fill an expensive medication, they may require you try less expensive therapies before the expensive medication is covered.
When a certain drug or therapy isn't initially covered, most insurance companies have an appeals or 'prior authorization' process. These basically involve your doctor providing evidence or an approved medical reason as to why you need a certain drug or therapy. If the reason is medically acceptable to the insurance company, they may approve it. If the reason is not acceptable, they won't.
Ask your insurance company for a copy of their drug formulary. If you are having an issue with a certain dose not being covered, talk to your pharmacist or insurance company to get an idea of why that dose isn't considered conventional. They will be able to tell you specifically why the dose you are prescribed is outside of the normal dosing guidelines. The main point here is that there is a reason why something isn't covered. It is important to find out and resolve the issue from there.
Lastly, insurance companies will set appropriate refill dates for your medications. If you are filling something 'too early', that would result in you having too much medication on hand, they can deny a refill until a more appropriate time.
