Investigative/Experimental Drugs, Immunosuppressants, and Psychotherapeutic Drugs

What follows is a breakdown of specific exclusions from coverage found in a typical individual health insurance policy.

 

((Typical wording*):

Limitations, Exclusions and Non-Waiver (cont.)

B. Exclusions (cont.) [In addition to other general Policy exclusions from coverage, the Policy does not provide coverage for any of the following, all of which are specifically excluded]:

52. Investigational use or experimental use of Prescription Drugs except for any Prescription Drug prescribed to treat a covered chronic, disabling, life-threatening Sickness or Injury on an Outpatient basis, but only if the investigational or experimental drug in question:

a. has been approved by the FDA for at least one indication; and

b. is recognized for treatment of the indication for which the drug is prescribed in;

(1) a standard drug reference compendia; or

(2) substantially accepted peer-reviewed medical literature;

53. Immunosuppressants;

54. Anti-fungal medication used for treatment of onychomycosis;

55. Psychotherapeutic drugs, including antidepressants;

56. Tobacco cessation products; and

57. Drugs prescribed for the treatment of any disease, illness or condition that has been excluded from coverage under the Policy by exclusionary rider, limitation or exclusion.

An investigational or experimental drug is a substance that has been tested in a laboratory and has received approval from the FDA to be tested in people. The drug may be FDA-approved for one disease or condition but still be considered investigational or experimental in other diseases or conditions.

Investigational or experimental drugs are generally not covered expenses. However, there is one instance when the insurance company will allow coverage – when your health condition is so serious that this type of treatment becomes a kind of last resort. Even in this situation there are still conditions to be met that at least ensure there is some reasonable foundation for the use of the drug. The term "indication" as used above, means a sign, symptom or medical condition that leads to the recommendation of a treatment, test or procedure.

Immunosuppressants are drugs that are used in immunosuppressive therapy to inhibit or prevent activity of the immune system. They are used to:

  • prevent the rejection of transplanted organs and tissues (e.g., bone marrow, heart, kidney, liver)
  • treat autoimmune diseases (e.g., rheumatoid arthritis, lupus, Crohn's disease, ulcerative dolitis)
  • treat other non-autoimmune inflammatory diseases (e.g., long term allergic asthma control).

They do have side effects and risks. When used, usually the entire immune system of your body loses its ability to resist infections and spreading of malignant cells. These drugs may be excluded from coverage because of their risky nature.

Onychomycosis: Onychomycosis is fungal nail infection (or ringworm of the nail). Toenails are more commonly affected than fingernails. In any event, medication for this skin problem is not covered.

Psychotherapeutic drugs: Psychotherapeutic drugs are not covered. They can generally be described as falling into four categories:

  • anti-anxiety (sedatives, tranquilizers)) – e.g., Valium, Xanax, Librium
  • anti-depressant – Prozac, Zoloft, Elavil
  • anti- manic
  • anti-psychotic

Anti-smoking drugs: Nothing used to help you stop smoking, prescription or otherwise, will be covered.

If a particular condition has been specifically and explicitly excluded from coverage under the policy, drugs used to treat that condition are not covered.

*Wording may vary from contract to contract and from state to state.