Choosing a Georgia ACA plan for a specific drug.
I need to buy health insurance on the Georgia exchange. I’m looking at gold plans and need to see multiple specialists each year.
To complicate things, I need to continue taking a very expensive biologic drug, Remicade, which only two of the companies cover. (Including the biosimilar/“generic” versions.) They are:
Ambetter – I know Ambetter has a whole bunch of lawsuits against it right now for having an abysmally bad provider network and the overwhelming customer consensus seems to be that they 🎵suuuuuck.
Oscar – I’ve been on Oscar only 2 months and it’s already been a nightmare experience, with even in-network doctors refusing to see me the second they hear I’m with Oscar. They also make it a pain in the ass to do anything in a way that will actually be covered, down to a flu shot. And the network sucks.
The other companies offering 2023 plans in my county do not include the drug in their formulary of covered medications, in any form, and say any ‘out of network’ drug has no coverage. So I’m assuming they’re a total no go— is that legit? I’m not entirely clear on whether this is the kind of thing that might get covered if the doctor makes an appeal for medical necessity. (I’ve jumped through all the typical hoops required for prior authorization of this drug: step therapy, formal diagnoses, etc. And there’s a strong case for this specific drug, since it’s one of THE recommended drugs for my combo of conditions and once you switch off it you can never switch back on without high risk of a bad allergic reaction.)
Do non-covered drugs EVER get covered by insurance plans? These are the other companies with available plans, but no coverage of my drug:
AetnaCVS
Anthem BCBS
Caresource
Cigna
Friday
Kaiser
What would you do if you were me? Awful Oscar? Awful Ambetter? Or try one of the others and see if I can get an override for the fact Remicade is not covered?
Really appreciate any advice, I feel like all my options are terrible.
