Getting a Formulary Exception

Jan 15, 2016

  1. beachbum2012
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    beachbum2012 Super Genius

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    So a client I signed up at T65 last summer told me at the time that she was on only one medication and it was expensive, but she was getting free samples. She said she told me what the name of it was but I don't have it in my notes, but that's besides the point now. So I get a call from her today saying the pharm rep that gave the samples out doesn't come around anymore and her drug plan doesn't cover the Asacol or Delzicol. I checked and only 10 of the 25 PDPs have it on their formulary in her area.

    What are her best options now? She said with a coupon it's still over $200/mo and would go up if her prescribed dosage does. I've clicked on the link thru her results on Medicare.gov and there are 2 assistance programs that may help: Healthwell Foundation and Proctor & Gamble's Assistance Program. Anyone have clients have any luck with these? How about requesting a formulary exception with Humana? Does that have a chance or is it a long shot?
     
  2. wehotex
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    wehotex Guru

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    I've had Good Results for off-Formulary authorizations from Humana in the past. It is my "go to" plan for PDP. Is there an actual Formulary alternative available? Has the patient tried those in the past?
     
    wehotex, Jan 15, 2016
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  3. mchris
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    mchris New Member

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    Have you checked needymeds.org to see what is available?
     
    mchris, Jan 15, 2016
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  4. beachbum2012
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    beachbum2012 Super Genius

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    It seems like there are a couple alternatives. Her drugs are classified as aminosalicylates so there are a couple meds on Humana's formulary that may work.
     
  5. kstein
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    kstein Guru

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    kstein, Jan 15, 2016
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  6. WCMason
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    WCMason Guru

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    Well-timed post. Just today got a call from a client with Humana PDP who was just prescribed Cialis for BPH. Referred him to member svcs for FE or PA to get the form as I was in my car. Will email this to him and save in iBooks. Thanks.
     
    WCMason, Jan 15, 2016
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