Biz principle's Rx rejected on group plan 12/1 renewal. Do "Coverage Reviews" work?

Nov 5, 2018

  1. yorkriver1
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    yorkriver1 Guru

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    I just saw on GoodRx that not many health plans cover Vyvanse and I don't know about the brand for the other rejected drug that is a quick acting asthma inhaler. Vyvanse is about $300 per month.
    The plan says they can ask for a "Coverage Review" if the doc thinks the Rx is the one that works. That's what the client is saying. Are successful coverage reviews for Rx on group plans a unicorn? Or do they get granted
    I had suggested an HSA for them last year, but they probably thought the Rx copays, etc, were comfy on their gold plan.
    I gave up this year, and with the cost of the drug, not sure the HSA would appeal to them. They will save more per month than the cost of the drugs, by about $200. The part that is rough is it won't lower their Max OOP.
    My first task is to listen to the telling off part. Grown up work day.
     
  2. leevena
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    Can be, but more reviews are rejected than approved. Good luck.
     
    leevena, Nov 5, 2018
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  3. yorkriver1
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    Yes, not guaranteed, but they do have all the evidence of other Rx not working, serious need, not just some normal ish kid on the Rx. I am looking into HSA alternatives. They aren't ready for HSA today, somehow, but I know they say they aren't using that much of their current MOOP, so a really good candidate and certainly well within income bracket to benefit from HSA, especially with a 12/1/18 renewal, possible full contrib for 2018, as long as also in the compatible health plan for all of 2019. The value is so obvious to me, but I get that it's scary to let go of the perceived safety of a gold plan.
     
  4. ABC
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    The doctor should be able to submit clinical date to support the treatment of vyanse.

    My advice is not to push a product on a group the does not want it.

    Move the coverage to a new carrier with a dual option.
    Then sell the employees on the HSA option.
     
    ABC, Nov 20, 2018
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  5. yorkriver1
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    Well, some good news. Apparently, after I researched things further, it was only one Rx that is no longer on formulary, it was 2 others moved from Tier1 to Tier3 from $10 to $75 copay, which still beats full retail at $400, maybe $350 with coupon. They are very happy. The one drug off formulary is under $75 with coupon. Day saved.
    Still no new takers on HSA--and I hit the owners with the option. I am going to go to a lower deductible HSA offer for next time. Also suggest employer make the reimbursement same as the next higher plan, in the form of an HSA deposit, or some such, so employer saves some, and employees feel less afraid. (I know the owners may not be able to get employer contribs to the HSA)
    When the employer is also taking the point of view of the covered employee, it's an interesting balance.