Actually, RayNY, I learn a lot from your posts, and I know that a lot of people look to your posts for solid information. You write with such factual documentation, that I chime in if I can add an item or two for clarity or accuracy. Your posts are usually 100% correct, and a few times about 99% correct. When people write posts that are no where near correct, most of the time I don't even bother responding.
High Cost Meds and ACA
- Thread starter kgmom219
- Start date
Actually, RayNY, I learn a lot from your posts, and I know that a lot of people look to your posts for solid information. You write with such factual documentation, that I chime in if I can add an item or two for clarity or accuracy. Your posts are usually 100% correct, and a few times about 99% correct. When people write posts that are no where near correct, most of the time I don't even bother responding.
- 599
Great, now I'm worried that any time Ann doesn't respond, I'm making a complete *** of myself
Not true. You write good posts. I'm talking about the posts that are so ridiculous that every agent on the forum knows it's nonsense.
Thread bump:
Hey guys! Thank you all so much for the posts and updates! Big definite help! Anyway, not sure if this would be the right thread to ask but if not, I apologize ahead of time.
I have a client that I helped enroll in Blue Shield of California who takes the brand name drug Keppra. I looked in the forumulary and it is listed. I understand that health plans will require beneficiaries to go through step therapy if there is a generic available. Assuming the doctor puts in the request for the brand name drug and it gets declined, what happens if the carrier says no on the appeal when that drug is clearly in the formulary ? Am I missing something ? (Why do I get the feeling as if I'm meant to be holding the dirty bag of laundry ?) Whatever info you guys can dish back I'd really appreciate it.
MIM
Hey guys! Thank you all so much for the posts and updates! Big definite help! Anyway, not sure if this would be the right thread to ask but if not, I apologize ahead of time.
I have a client that I helped enroll in Blue Shield of California who takes the brand name drug Keppra. I looked in the forumulary and it is listed. I understand that health plans will require beneficiaries to go through step therapy if there is a generic available. Assuming the doctor puts in the request for the brand name drug and it gets declined, what happens if the carrier says no on the appeal when that drug is clearly in the formulary ? Am I missing something ? (Why do I get the feeling as if I'm meant to be holding the dirty bag of laundry ?) Whatever info you guys can dish back I'd really appreciate it.
MIM
That's a great question. No clue. How can I find out ? (All I know is that it's on the formulary.)
Thank you for your help!
MIM
- Thread starter
- #47
It depends. 
Typically on step therapy, the company or PBM wants to know that they patient has tried older, cheaper drugs prior to taking the most expensive.
Keppra is a very expensive anti-seizure drug.
The company/PBM wants to know that the patient tried a cheaper drug(s) first. (In this case, its probably Dilantin and/or Tegretol).
What it is does NOT mean that they have try Dilantin or fulfill other requirements of the step therapy rules for Keppra WHILE ON THE CURRENT POLICY.
A pharmacist can actually make a decision based on medical history that the doctors office provides, which doesn't have to be carrier specific.
My advice is to call the pharmacy line and get the step therapy rules for this specific drug. Discuss it with the client and see if they have fulfilled it. They most likely have, so its just a PIA to get it covered.
Typically on step therapy, the company or PBM wants to know that they patient has tried older, cheaper drugs prior to taking the most expensive.
Keppra is a very expensive anti-seizure drug.
The company/PBM wants to know that the patient tried a cheaper drug(s) first. (In this case, its probably Dilantin and/or Tegretol).
What it is does NOT mean that they have try Dilantin or fulfill other requirements of the step therapy rules for Keppra WHILE ON THE CURRENT POLICY.
A pharmacist can actually make a decision based on medical history that the doctors office provides, which doesn't have to be carrier specific.
My advice is to call the pharmacy line and get the step therapy rules for this specific drug. Discuss it with the client and see if they have fulfilled it. They most likely have, so its just a PIA to get it covered.
My advice is to call the pharmacy line and get the step therapy rules for this specific drug. Discuss it with the client and see if they have fulfilled it. They most likely have, so its just a PIA to get it covered.[/QUOTE]
Yes, it is a royal pain as I am learning. This is just my opinion but I think how the benefits are laid out vs how it really reads in the eoc can be somewhat misleading. The copays are listed for generic, preferred brand, and non preferred brand drugs but I think that they should put the side note that if there's a generic available for a brand name, the subscriber/client will have to pay the difference between the two as part of the plan summary rather than on the eoc. The fact that they place the copays for preferred and nonpreferred brand names without an additional explanation there would lead many to possibly sign up for that plan and learn about their real copays when it is too late. I can't imagine how many patients apply for prior authorization and appeals only to get declined after waiting for a seemingly endless amount of time. I don't know. What do you guys think ?
I still don't know how to find out. What would it mean either way ? (Sorry, I still don't understand.)
Thanks for your responses guys! You really know you're stuff! I wish I could post more often and sooner but it seems I'm always so busy trying to work and put out fires.
MIM
UPDATE: Prior authorization got declined. Waiting on the appeal. Will probably get declined too but still hoping. I learned that after the appeal, one would go through and IMR with the Department of Managed Health Care. Anybody have any experience with this ? Thanks!
Yes, it is a royal pain as I am learning. This is just my opinion but I think how the benefits are laid out vs how it really reads in the eoc can be somewhat misleading. The copays are listed for generic, preferred brand, and non preferred brand drugs but I think that they should put the side note that if there's a generic available for a brand name, the subscriber/client will have to pay the difference between the two as part of the plan summary rather than on the eoc. The fact that they place the copays for preferred and nonpreferred brand names without an additional explanation there would lead many to possibly sign up for that plan and learn about their real copays when it is too late. I can't imagine how many patients apply for prior authorization and appeals only to get declined after waiting for a seemingly endless amount of time. I don't know. What do you guys think ?
I still don't know how to find out. What would it mean either way ? (Sorry, I still don't understand.)
Thanks for your responses guys! You really know you're stuff! I wish I could post more often and sooner but it seems I'm always so busy trying to work and put out fires.
MIM
UPDATE: Prior authorization got declined. Waiting on the appeal. Will probably get declined too but still hoping. I learned that after the appeal, one would go through and IMR with the Department of Managed Health Care. Anybody have any experience with this ? Thanks!
- 1,735
I found a person at Express Scripts who was helpful in discussing the full cost of a name brand drug one of my clients takes. When plan switching, this was important, due to big deductible. Same carrier, different plan, still Express Scripts. Not sure if there is someone at Express Scripts who could review the situation with step therapy.
Also, the person at the name brand drug company who handles their pharmacy assistance program for the specific drug in question was extremely knowledgeable and helpful, willing to spend time on the phone.
I will bring up the question about the paying the difference between generic and brand if generic available part at next meeting where there will be BCBS rep.
Getting name brand step therapy exceptions, not experienced, yet. Not looking forward, but it's bound to happen. Will follow this thread.
Also, the person at the name brand drug company who handles their pharmacy assistance program for the specific drug in question was extremely knowledgeable and helpful, willing to spend time on the phone.
I will bring up the question about the paying the difference between generic and brand if generic available part at next meeting where there will be BCBS rep.
Getting name brand step therapy exceptions, not experienced, yet. Not looking forward, but it's bound to happen. Will follow this thread.
Last edited:
Similar threads
