Insurance companies often take their cue regarding what they will need to cover to stay viable in the market from “FDA approved” treatments and protocols. This is a prohibitive misuse of this label and how proper healthcare works. Though off-label use of FDA approved treatments (such as liquid antigen sublingual immunotherapy) is not only legal but is counted on for physicians to be able to provide patients with the best individualized care possible, many off-label treatments are declined for coverage by insurance companies despite a qualified physician’s expertise and recommendation of the treatment. This is why you likely have experienced pushback from your insurance company when your doctor has recommended a specific treatment for you in the past, or had to go through a tedious prior approval process (most likely your doctor’s office did it for you), or had to switch to a different medication or treatment from the one your doctor recommended specifically for you at your insurance company’s demand if you wanted their coverage benefits.
It is important to know that an insurance company is not required to cover you for the most beneficial treatment for your specific situation. Many times, the most appropriate treatment for you may be an off-label use of an FDA approved treatment, which likely will not be covered by your insurance. Your option then is to make the sometimes tough financial choice about whether or not to go with your insurance company’s covered treatment or your doctor’s specific recommendation for you (or your desired treatment) and pay out of pocket. Sometimes it is not as difficult of a financial choice, especially if you have a high deductible plan and are paying out of pocket either way. You are not alone in this process, however, and can always ask your trusted physician for advice. She or he can help you weigh out the risks and benefits of each option so that you can make the best decision based on all the factors combined.