With many plans, you must get a referral from your primary care provider before you can see a specialist. To have surgery except in an emergency, you need approval from the health plan itself. As for medications, some plans offer pharmacy benefits based on a closedformulary, which means they will only pay for drugs listed in the formulary. A health plan's decision about whether to reimburse for a particular treatment is based on a number of factors. Decisions are also based on guidelines that spell out what is appropriate for particular disorders.
Many plans use standardized guidelines, developed by outside organizations.
If a situation isn't covered by the guidelines, the HMO's medical directors make the decision. Many plans have also developed their own criteria, based on studies reported in peer-reviewed medical journals. A plan's internal criteria, which may cover hundreds of different therapies, are reviewed and updated regularly. There are a number of things you can do if your health insurance carrier denies payment for health care you feel you need. First, ask your primary care physician to talk to the plan's medical director and do battle for you.