Cimzia and Medicare Advantage or PDP, anyone have success with prior auth.

[yorkriver1]

Client has to drop individual coverage now that they will soon have Medicare. This is the self injectible unit from pharmacies, not infusion at a facility.
No more copay card for "commericial" insurance once on Medicare.
There are 2 Medicare insurers in the area that will consider the drug, but require prior authorization, no guarantee of coverage, for this $6000 a month drug. 2 months pay, about $3500 OOP for client then catastrophic for the rest of the year, $0 oop.

 

[somarco]

Consider a grant . . .

Home

Helping the underinsured afford critical medical treatments — because no one should go without essential care. Learn more

www.healthwellfoundation.org

PAN Foundation - Home

PAN Foundation is helping people with life-threatening, chronic, and rare diseases get the medications and treatment they need.

www.panfoundation.org

 

[yorkriver1]

Consider a grant . . .

Home

Helping the underinsured afford critical medical treatments — because no one should go without essential care. Learn more

www.healthwellfoundation.org

PAN Foundation - Home

PAN Foundation is helping people with life-threatening, chronic, and rare diseases get the medications and treatment they need.

www.panfoundation.org

Thanks, will try the first one, the second one is out of funds for RA.
My concern is a refusal of prior authorization. The person can afford the $3500 or so then $0 after catastrophic.

 

[somarco]

I understand your concern about prior authorization . . . but if they qualify for a grant, those prescriptions do not run thru Part D, which eliminates the PA stuff.

Run the numbers (if they qualify). If the grant costs the client less than $3500 go for it.