The People's Perspective on Medicine

How Risky Is It When Insurance Companies Overrule Doctors?

When a physician prescribes a medication, should an insurance company be permitted to reject that decision? Are insurance companies practicing medicine?

Doctors don’t always know best, but they certainly know their patients far better than an insurance company representative. Physicians used to be able to prescribe medications without being second-guessed. That seemed logical. After all, health professionals have the expertise to determine the most appropriate treatment for any given patient. But now insurance companies can make life and death decisions without knowing important details about a particular patient’s health. Are these insurers practicing medicine without a license?

Doctors, Patients, Insurance Companies and Prescriptions:

In most states a doctor must perform a medical evaluation before prescribing any medicine. As far as we can tell, insurance companies do not perform medical exams. And they may not always review medical records.

That’s the startling report by Linda Girgis, MD, in an article published online in MEDPAGE TODAY’S KevinMD.com (March 29, 2018)

Here is the gist of the article:

“Earlier this month, it has become known that the former medical director of Aetna, Dr. Jay Ken Iinuma, admitted under oath that he sometimes did not look at any medical records when making these determinations. Additionally, when he did review the medical records, he reviewed only portions of them.”

“As doctors, we all know patients who had care denied in spite of the fact that they really needed it. It seems that the more we appeal a decision based on evidence-based medical practice, the less likely it is to be approved. As it is, the insurance companies are not required to follow evidence-based guidelines and often follow the ones they choose, creating their own guidelines with the goal of cost reduction, not clinical outcomes.”

Insurance Companies Can Just Say NO:

Insurance companies can refuse a particular prescription, demand prior authorization through a third party (pharmacy benefit manager or PBM) or substitute a different medicine for the one the doctor prescribed.

We are outraged by the high prices drug companies often charge for brand name medicines. But if a doctor determines that the brand name is essential for the health of a patient, we do not understand how an insurance company can refuse to pay.

The Case of the Dying Mailman:

Many years ago, we heard from our mailman that he had spent weeks in the intensive care unit as a result of an insurance company decision. His doctor had prescribed brand-name Zantac (ranitidine) for his acid reflux. This acid-suppressing drug had worked well with no side effects.

When generic cimetidine (Tagamet) became available at a much lower price, the insurance company insisted that he switch. Not long after starting on cimetidine, he developed a life-threatening reaction called Stevens-Johnson syndrome (SJS).

In this condition the skin blisters and peels off. Mucous membranes are also affected. The mouth can become extremely sore and inflamed. Infections, pneumonia and organ failure are potential further complications.

After weeks in the hospital, our mailman finally began to recover. It took months for him to get back to work. The insurance company spent an untold amount of money for intensive care.

When it came time for him to fill his next prescription for Zantac, however, the company again tried to insist that he take cimetidine, the drug that had left him close to death. Needless to say, he chose to pay for brand-name Zantac out of pocket instead.

A search of the medical literature turned up other cases of Stevens-Johnson Syndrome linked to cimetidine. The first we found was published in The Lancet on August 19, 1978.

The authors noted that:

“Cimetidine was the only drug which the patient was taking before the onset of the Stevens-Johnson syndrome. Neither could we find evidence of any other precipitating factor. To be sure that cimetidine was the cause of the problem we would have had to challenge the patient with the drug; however, we felt that this was ethically unjustifiable.”

Amen to that! How, you might wonder, could an insurance company be so short-sighted as to require a patient to take a medicine that had nearly killed him? The costs to treat this adverse reaction were astronomical. Perhaps there was little, if any, actual thought involved in the decision to reject the brand name Zantac. If an insurance company physician was involved in this decision,  we would propose that he might be vulnerable to malpractice. Any state legislator that allows such incompetence from insurance companies should be booted from office.

Penny Wise and Pound Foolish:

This is not the first time patients have been harmed by cost-saving decisions made by insurance companies. A cardiologist we know often spends hours on the phone trying to convince an insurer to cover the brand name medicine he believes is essential for the health of his heart patients. This is time not spent caring for patients directly in the clinic.

He has had patients with hypertrophic cardiomyopathy develop complications because a generic beta blocker did not perform as expected. Patients with heart failure need to control fluid retention, usually with a diuretic like Lasix. This cardiologist has seen patients deteriorate when taking certain generic furosemide formulations that the insurance company required and the pharmacy dispensed.

Readers Speak Out About Insurance Companies:

Readers have expressed their own outrage. One person wrote:

“I am very upset about insurers that refuse to honor prescriptions for brand name drugs. I was on losartan, but it was recalled because it was contaminated with a carcinogen. I started buying Cozaar instead, but my insurance doesn’t cover it. I guess the insurance company would prefer I get cancer.” 

Another reader noted:

“In the past few years, I’ve had problems with four generic drugs not performing like the original brands. In each case, it has affected my health negatively. I’ve had additional difficulty due to insurance company intractability.

“This situation is becoming increasingly frightening, in part due to the influx of medicines from China, and I have a bad feeling that it is going to get a lot worse before it’s addressed.”

We do not disagree. The FDA has congratulated itself on the increased number of generic drugs it has approved over the last few years. This accelerated approval process means that more foreign-made pills are destined for the U.S. marketplace.

We are not opposed to manufacturing in other countries. That said, we want much better scrutiny of the process and we want the FDA to test the quality of all the drugs entering this country from abroad.

Patients vs. Insurance Companies:

We receive an extraordinary number of comments from visitors to this website. They share their stories about a wide range of issues. We hear frequently from people dealing with insurance company challenges.

Martha in North Carolina has serious dry eye syndrome:

“I have been prescribed Xiidra. It’s about $625 a month. My insurance refuses to cover it, nor will they apply it to my out-of-pocket max. The manufacturer will not allow use of their savings card because I have insurance. None of this makes sense to me. The real question is, how do I get the drug at an affordable price?”

Martha asks a great question. We do not have a good answer. She is caught between the manufacturer and the insurance company and neither wants to cut her any slack.

Lifitegrast (Xiidra) is a relatively new treatment for severe dry eyes (Journal of Pharmacy and Pharmaceutical Science, Jan. 9, 2019).  It works differently from previous dry eye drugs. It reduces inflammation. Summarizing the clinical data, we would say that roughly 15% to 20% of patients with dry eye disease saw a substantial improvement with Xiidra compared to those on placebo. Not a home run, but a solid double for symptom relief.

Sadly, the price, even with a coupon, is over $500. In Canada the cost is also very high. Without insurance company assistance, this medicine will be out of reach for most patients.

A far more serious situation came from George. He wrote about prostate cancer.

“My oncologist prescribed Leukine (sargramostim) injections to stimulate my immune system and lower my PSA. My doctor believes that if Leukine is added to my other medications I can maintain a durable remission against prostate cancer.

“The cost of Leukine is over $3,600 a month. The insurance company has refused to pay for this drug. I cannot possibly afford this medicine. My oncologist appealed the insurance company’s decision, but that didn’t work. How can an insurance company refuse the doctor’s decision?”

We fear that it happens all the time. States apparently allow insurance companies to get away with this practice. We do not understand it either.

We don’t think that insurance companies should be allowed to play doctor. There must be other ways to help control rising health care costs. The physician alone is in the best position to determine the most appropriate medication for the patient.

What Do You Think?

Please share your own experience with insurance companies, for better or worse. Should insurance companies be allowed to make life and death decisions about treatments? You can add your thoughts or story below in the comment section.

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About the Author
Joe Graedon is a pharmacologist who has dedicated his career to making drug information understandable to consumers. His best-selling book, The People’s Pharmacy, was published in 1976 and led to a syndicated newspaper column, syndicated public radio show and web site. In 2006, Long Island University awarded him an honorary doctorate as “one of the country's leading drug experts for the consumer.” .
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I took a generic version (Zolpidem) of Ambien for years and used a specific manufacturer, as other generics didn’t work. In 2015, the manufacturer stopped producing Zolpidem, and I had to try other generics without success and suffered through 60 days of sleep problems. Due to the class type of Zolpidem, you can only try a new brand every 30 days, even if the brand doesn’t work.

My sleep doctor then prescribed Ambien instead of the generic, and I also reduced from 10 mg to 5mg with a goal of not using any sleep medicine. I wanted to reduce slowly, as I was also adapting to a CPAP machine. After one year, Cigna stopped covering Ambien despite appeals, saying that “generics had been around a long time”. I researched on the internet which generics were most successful and eliminated the two that hadn’t worked for me. I am now using 2.5mg of Sandoz-brand occasionally. I find that Zolpidem is half as effective as Ambien, but since I am reducing anyway, it works for me. I am worried because Sandoz has to be special-ordered, and I am afraid it won’t be available. So lessons are: generics are NOT the same as the brand name drug, and there is a great variance among generics to the point that some are not effective at all.

Look at all the generic drugs that people are having problems with. The drug companies want to pay the least amount of money so a patient is told they have to take them. The problem with the generics, I believe, are the fillers. They are producing the generics with the cheapest ingredients. My husband has had major health issues these past two years. I try desperately to keep him off drugs. He is taking Niacin for cholesterol for a number of years and it has kept his cholesterol in check. He had a bad reaction years ago to a statin. Yet despite this, his doctor has been pushing for a statin. America has become a pill popping country. Just look at the opioid crisis. The advertisements for pharmaceutical drugs. We need to be our own advocates for our health. If you are not comfortable with drugs, look for natural solutions. The body is fantastic, it wants to heal. It needs our help though not always with drugs. There are times drugs are needed. However, when you start piling one drug upon another which is what occurs, there will be consequences. Plus now, the drugs we are forced to take are not quality.

Four years ago my daughter’s neurosurgeon used a type of “superglue” to repair her skull during a craniotomy. This was a product he had used successfully for several years and that was marketed for that purpose. The insurance company denied the claim, and we received a bill for $17,000 for the “glue” which came in a tube similar in size to actual superglue. Her doctor was outraged that the insurance company was trying to decide what he should use in his practice.

Last year the same doctor and the same insurance company had to argue again about whether or not my daughter needed an MRI to follow up on her brain tumor. Maybe they had expected him to look into the hole that would have been left in her skull if he hadn’t used the “superglue” to close it up.

If you think that an insurance company cares about anything except their bottom line, then you are naive. They also successfully lobby (i.e. payoff) 99% of Congress members. The answer to this problem is simply SINGLE PAYER Medicare for all.

I took Cozaar for years, insurance said take generic, ended up in ER with my blood pressure skyrocketing. Now I take Benicar, Insurance said no take generic, blood pressure did the same thing again. Back to Benicar and now insurance company says no you can’t take it. Doctor said try Amlodipine Besylate, another generic, ended up being allergic to it. I am allergic to the fillers that they put in generic drugs. Let’s face it Big Pharma rules insurance companies and we are the victims of them!

I just plain don’t buy into it Don’t see doctors; don’t buy expensive drugs, walk my butt off,

I’ve had the same experience with Cigna Healthspring as my Medicare drug plan—-almost all meds are rejected until the dr is consulted and some are rejected even after consulting with the dr. This, after my actuary husband checked that all the drugs on my list were covered. I keep getting letters about drugs not being covered almost every time I pick up a drug. Then I have to call. Livalo, after they initially said it was covered, fell into this category. Now some that the dr prescribed— for ezcema, an inhaler —— were both rejected. They chose another inhaler! Forget the ezcema med—-they won’t allow it. This infuriates me that an insurance company can decide what meds to prescribe!! And, ironically, they are advertising on your site. Get them off, which is what I am going to do as soon as there’s open enrollment.

I have been going without my prescribed blood pressure medicine because my health insurance (considered a premium plan) refuses to pay for it. But it seems to me that the price of the drug is what is ridiculous. I was taking a generic version of an old medicine – Olmesartan. How can this possibly cost over $600 a month?

My doctor wanted to prescribe Januvia for blood sugar control after other medications didn’t work and/or side effects that were intolerable. My insurance company, Care 1st, said denied my doctor’s prescription because my blood sugar was TOO HIGH! They wrote me and suggested I start taking insulin injections. I’ve decided to live with terrible side effects, nausea and diarrhea, to get my blood sugar down hoping that they will allow januvia. My doctor told me that my insurance company requires that I try all other drugs before they’ll t let me take the stronger drug so I did that and the consequences were disastrous.

I ha e very high cholesterol and triglycerides. I had been taking meds for cholesterol since my mid-30’s. I’m now In my seventies. I had to stop statins about 10 or so years ago. I could barely move because of them. A few years ago, I got into a study for a medication with the same ingredients as Repatha. Checking my cholesterol, my doctor let me know I was on the real stuff. My cholesterol had gone down to 150. The study was canceled, and I was back on nothing. My doctor wouldn’t request approval for Repatha for me from my insurance company because I didn’t meet their criteria – I hadn’t had a heart attack yet! My grandmother died of heart disease, my uncle had a heart attack in his 30’s,and my mother had a silent heart attack. So I’m still taking nothing and hoping the pains I get are not “The Big One.”

They can also deny medical tests. I went to my doctor for several years with problems that seemed to indicated thyroid problems, These included almost all the systems associated with hypothyroidism. I doctor would give me the standard test that I always passed. So, I didn’t have thyroid problems until a scan for another problem showed up nodules in my thyroid and I had the start of a goiter. I received a story about the doctor’s aunt that was fine but had a goiter. I finally gave up and went to a naturapath who prescribed thyroid medicine (of course, Medicare wouldn’t cover it). I feel so much better now. I understand there is a better test for Thyroid issues, but its expensive so insurance doesn’t want it used.

My doctor recommended labwork due to a risk factor for medication I take. My insurance company denied payment and stated the labs are considered investigational and not medically necessary. My primary care doctor wrote the insurance company a letter. It was denied twice by the insurance company and the third appeal was with an outside agency through the Dept of Insurance. The outside agency ruled in my favor for the labwork to be covered. It was worth the time and paperwork.

For at least the last 20 years, the insurance companies have been practicing medicine, not the doctors. Many employees of the insurance companies who make medical decisions, have little or no medical training. In some cases I suspect it is alll financial.

I think it is absolutely absurd that insurance companies are allowed to get away with this kind of nonsense. These shenanigans need to be stopped. I am a healthcare professional and feel this is definitely practicing medicine without a license.

Express Scripts has also denied many of my prescriptions. They have been designated as the pharmacy benefit management for my Medicare coverage. All of these medications were previously covered (some for many years) without any problems.

My doctors have spent countless hours justifying these medications and some are still not approved. In some instances I have been advised to purchase OTC products which were not even close to equivalent. I believe the MO of these PBM’s is to cause as much aggravation as possible to patients and doctors so that they give up.

NO!! We don’t pay (high) monthly premiums so the insurance can play doctor!!

My eye doctor prescribed Avennova for my chronic dry eye disease due to Graves Disease. It is the only eye spray that works to keep me from my dry eye problem. In 2018, my insurance covered it. Now n 2019, my insurance company will not cover it. My physician appealed it, but they still would not pay. Luckily my pharmacist found coupons to help lower my cost. This issue is getting out of control. Our govt. needs to take a stand. We the American people need to be heard!

If a person has a car wreck, you are only covered for the insurance dollar amount that you agreed to pay for, when you took out the insurance. To ask a health insurance company to provide a person with unlimited coverage, for any possible drug, you would have to allow the company to increase rates in an unlimited manner, anytime they were affected by cost increases.

The real answer is to have universal healthcare that brings everyone into the pool and allows for better bargaining and regulation of costs. These above examples are a definite way of showing that the “rationing” people fear with universal coverage is already happening under the current system.

I have had several problems with our insurance. My husband is a retired Naval veteran, so we have Humana Tricare coverage…run by our government. I take Lyrica for severe nerve pain. Three years ago, Tricare told me I had to get my prescription filled by Express Scripts ( their pharmacy that mails you your medicine). They do not like to fill my Lyrica until the last minute–causing me to run out of my meds before they get my refill to me. Lyrica is very expensive, costing hundreds of dollars for a 30 day supply. When I run out of Lyrica, the withdrawal symptoms are horrible; so, I often have to get my doctor to call a 10 day supply into my local pharmacy so I can get by until my refill arrives. This usually costs around $200 out of my pocket. and they never reimburse me. I don’t think the insurance should be able to dictate where I get my prescription filled…all about the money!

After being sick all my life, always in pain, at the age of 50 I was diagnosed with Lupus. My rheumatologist has tried several treatments that have sparked intolerable side effects. She told me I have to be patient because insurance won’t pay for the newer meds that she thinks will actually help me until after I’ve tried all these other medication that do not jive with my body chemistry (some of these meds have the side effect of possibly causing Lymphoma!!!). So, I definitely agree that these big insurance companies have way too much power. The government needs to step in and reform the whole thing.

I have had the same situation with Rosuvastatin, brand name Crestor. Quite simply, the blood tests don’t lie. My cholesterol numbers are excellent with Crestor, and I don’t have the back cramps. It is the opposite with Rosuvastatin. My numbers are not great, and it looks like the product doesn’t really work for some reason. With Crestor I don’t have the charlie horse cramping in my back and legs. I have switched back and forth between the two numerous times, but each time, even with a doctor’s direct involvement, the insurance company refuses to offset the cost. A 30 day supply of Crestor is around $300.00.

What can we do to get this nonsense to stop? The insurance companies know that they are “practicing medicine” without a license. They are not the doctor that I have chosen. I already pay dearly for insurance. How did all of this get so out of control?

My wife used Vagifem for several years without incident. Now there is one generic version that is available – Yuvafem. My wife tried it but experienced irritation of her entire genital area, bladder infections, and yeast infections. We thought it might be fillers that the generic manufacturer used versus what the brand manufacturer used. We appealed to the insurance company to provide some level of coverage such as 50% of the cost, which is what they offer for non-preferred brand. They refused. The brand version is actually excluded from coverage, leaving the generic Yuvafem as the only covered option. We now have to pay the full price out of pocket.

In addition to presenting excellent, rational complaints about insurance companies being out of their lanes, we ask that PP also provide recommended action plans that readers can do to help address this situation. Don’t just moan and groan to us. Tell us what needs to be done to help rectify the problem.

It is certainly clear that this is all part of the government-sanctioned extortion allowed on behalf of the pharmaceutical and insurance industries, and it will continue as long as both parties continue to take money from them.

I was prescribed Lexapro by my doctor to help with my anxiety/depression. It worked quite well for me. Then the insurance company decided that I had to use Escalipram, the generic. I switched to the generic, and it did not help as well with my social anxiety, so my doctor increased my dosage to 30mg, which helped me. The insurance company decided they will not pay for more than 20mg, and so I am left trying to deal with my social anxiety that sometimes effects my ability to work. It doesn’t affect the insurance company if I miss days of work. This is totally insane.

My wife has been on Lexapro for years and we request the brand name when submitting the prescription to the pharmacy. Three years ago the pharmacy substituted generic and she started taking it. Within days she literally went crazy with horrible withdrawal symptoms. Since then we have been diligent in making sure that the brand name is dispensed. Unfortunately, Aetna has now decided they will no longer cover Lexapro, so we now have no choice but to pay out of pocket (about $900 per month). It is not ethical for the insurer to exclude the only therapy that works in order to avoid the cost of the brand name.

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