Formulary Question

I have a question about how healthcare companies choose and comply with regulations regarding their formularies.

I am diagnosed with narcolepsy and have been on Wakix for 3 months; my old insurance approved it on the first try in less than a day as I met the guidelines, despite the fact it’s a $10k/month med. If you switch insurance to BCBS, Wakix is now listed as “non-formulary” but not “not covered.” I start thinking ok, the medication is specialized and quite expensive, maybe my doc prescribed a name brand over generic, so I click on the alternative options on BCBS, and there are none. Zero other drugs to try or that act similarly per BCBS own docs, yet it’s not covered.

Also of note is it is covered as teir 4 in other national BCBS plans, just not in the BCBS CT ACA marketplace plan, the same place I got my old insurance.

I get if the insurance company can save money by going with an equivalent that’s maybe not 100% similar, but in this case the drug is non-formulary without even giving an alternative. How is that possible? Narcolsepy is a covered condition how can they not offer the only drug in a class to treat it? (H3 receptor antagonist)

One more generic question Why don’t governments (state or federal) set formularies or mandate drugs be covered based on FDA approval? Barring a cheaper equivalent being available).

submitted by /u/Inevitable_Pop3008
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