David Chaplin-Loebell had been using the same asthma maintenance drug, Advair Diskus, for 10 years. Despite a recent exacerbation, his primary care physician and his specialist agreed back in January that the Advair Diskus was his best option.

But when he showed up at his pharmacy for a refill in February, Chaplin-Loebell, an IT director, was told that Advair was no longer covered by his insurer, Aetna. The denial contained the confusing message “requires pre-certification or step therapy,” and that was the only explanation he got from Aetna. His pharmacist said he’d need to be prescribed something different, but didn’t know what.

Policy Woes

In most cases where drugs are suddenly denied by an insurer, it’s because the insurer has updated its formulary, the list of approved drugs it will cover. The insurer’s goal is “to keep access to prescription drugs affordable, which can result in changes to drugs included in the formulary,” says Sally Poblete, a health insurance expert and CEO of Wellthie, a health care technology company that simplifies health insurance options for consumers.

Poblete says insurers often do this when “some drugs become more expensive, and cheaper drugs to treat the same condition become available.”

When Chaplin-Loebell called his physician, the doctor suggested he check to make sure Aetna hadn’t removed Advair from its formulary. “It hadn’t,” Chaplin-Loebell says. “That would have required advance notice, and I would have had time to prepare for it.”

“Insurance companies keep their websites updated, but it’s the consumer’s job to stay up to date on the policy,” says Linda Adler, CEO and founder of Pathfinders Medical, a company that advocates on behalf of patients in medical billing and health insurance disputes, while also helping them navigate all aspects of their medical care.

But Chaplin-Loebell’s policy didn’t change, and there were no updates online. So when he received a denial at the pharmacy, his doctor filed an appeal to get the drug covered. Because he was left without options, he spent a week off his preventive medication. The appeal was then denied, and he still had no answers about what he was supposed to do.

Persistence Uncovers an Answer

To add insult to injury (or perhaps illness to insult), the whole ordeal came about at a very bad time. “The problem occurred in the middle of the worst asthma exacerbation I’ve ever had in 30 years as an asthma patient,” Chaplin-Loebell says.

Sick and frustrated, he made several calls to his insurer, doctor and pharmacist before “it finally became clear that they were requiring me to try a different drug before authorizing Advair again,” Chaplin-Loebell says. In other words, Advair is still on the formulary – but because it’s relatively expensive, Aetna would rather pay for a cheaper drug if it works and a patient can tolerate it.

His doctor put him on Symbicort, but “was also kind of wishy-washy about whether he felt like Symbicort was an acceptable substitute for Advair,” Chaplin-Loebell says. That only added to his growing anxiety surrounding switching drugs.

Finding a Solution

“Even though it can take you by surprise, don’t panic,” Adler says. “In most cases you’ll find other drugs on the formulary, other things that will work.”

And to prevent future surprises, she advises consumers to stay on top of health insurance news as well as their own insurer’s website and formulary. “You want to stay informed from the get-go,” she says, which minimizes the chance of being surprised by a denial. You can always ask for copies of your policy and formulary.

It works in reverse, too. If you want to switch drugs because your current prescription is too expensive, check your formulary and call your doctor to talk about it. “You can ask about mail-order options and confirm you really need the drug,” Adler says. “You have other options. It just takes a little legwork.”

Fortunately for Chaplin-Loebell, things are working out for him now. “Symbicort seems to be working fine for me, although the question of whether it is as effective as Advair is a long-term one that I hope someone has researched,” he says.

He’s leaving the heavy-duty research up to scientists, but Chaplin-Loebell did a little math for himself. Symbicort is indeed cheaper for Aetna than Advair, even though his portion, a $50 copay, is the same for either drug. The difference? “This entire rigmarole saves them $15.04 per month,” he says.