Opinion ID: 6334161
Heading Depth: 2
Heading Rank: 3

Heading: Fisher’s EffexorXR Prescription

Text: The February 19 Document included the following clause: An additional charge may apply when a Prescription Drug on a higher tier is dispensed at Your or Your Provider’s request, when a chemically equivalent Prescription Drug is available on a lower tier unless We approve coverage at the higher tier. You will have to pay the difference between the cost of the Prescription Drug on the higher tier and the cost of the Prescription Drug on the lower tier. The cost difference must be paid in addition to the lower tier Copayment or Coinsurance. No. 20-3148, App’x at 334. This is widely known in the health insurance industry as a “Choose Generic” provision. Under a Choose Generic provision, a member must first try the generic version of a medication before Aetna will approve the brand-name equivalent. If the member chooses the brand-name drug, without a waiver of the Choose Generic requirement, then the member must pay an additional charge equal to the difference in cost between the brand-name and the generic. The member can request a waiver of the Choose Generic provision, but Aetna requires the member’s doctor to provide documentation showing that the brand-name drug is medically necessary. This Choose Generic clause was not present in the January 9 Document. 10 Fisher suffered from severe recurrent major depression and was prescribed EffexorXR. EffexorXR is a brand-name drug for which a generic, venlafaxine, exists. The Aetna Formulary, Aetna’s prescription drug guide, classified EffexorXR as a Tier 3 drug, which meant it was subject to the Choose Generic provision. The cost of a 30-day supply of EffexorXR ranged from $350-$500 while the cost of venlafaxine was $35. Fisher submitted a prescription for EffexorXR on January 29, 2014, but Aetna declined to cover Fisher’s EffexorXR prescription. Fisher’s doctor submitted a form requesting Aetna cover EffexorXR which Aetna then approved. Importantly, however, Aetna did not waive the additional charge applicable to the brand-name drug. Aetna acknowledged that EffexorXR was “approved for coverage” but did not approve additional reimbursement for it. No. 20-3148, App’x at 63-64, ¶ 79. This approval allowed Fisher to purchase EffexorXR at her pharmacy at Aetna’s negotiated price, but did not permit Fisher to receive reimbursement for her purchases. Fisher’s pharmacy submitted claims to Aetna on behalf of Fisher for the price of EffexorXR. Aetna created records showing that Fisher had to pay for the prescription and posted the records to a website accessible to Fisher. The 11 maximum amount Fisher’s family paid for medical products or services in 2014 that could count toward their out-of-pocket limit was $8,951.14. Fisher continued to purchase EffexorXR in 2015 when she was on a new health policy administered by Aetna. The 2015 policy contained the same Choose Generic clause as the February 19 Document. Aetna applied the full cost of Fisher’s January, February, March, and April purchases of EffexorXR ($540.11 each) to her 2015 deductible. Fisher asserts she met her deductible on May 4, 2015, but Aetna did not reimburse her for any costs after that date. On August 31, 2015, Fisher’s purchase of EffexorXR took her annual medical spending over $6,000 which she alleges is above her out-of-pocket limit, but Aetna still refused to cover Fisher’s purchases of EffexorXR for the rest of 2015.