How Much Sucess Do You Have Getting PA or Exceptions?

[kennethbroyles]

Let me say I don't have problems getting a PA for Rx's in the past. I had an appointment last night with a man (LIS <65, lost QMB because of wifes PT job) who is on a new pain Rx "Suboxone." Humana is the only MAPD that say's "not on {complete} formulary" of the 3 HMO's in the area, and Humana is the only MAPD that his PCP/Pain Management.. will accept.

Any feedback on PA's or exception? I can't remember ever remember needing a exception in 7 yrs of enrollments, but Pa's are common-place.
BTW..I didn't take an application.

What do "Y'all" think.
​

 

[MedSuppPro]

Some pain management services can be pricey.

Is a MedSupp possible?

What do "Y'all" think.​

Rick may not be able to understand "Y'all".

He may need a Redneck Dictionary.

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[kennethbroyles]

MedSup is not possible do to cost. I am really curious what MAPD agents find when requesting an exception, in more general terms, if PA doesn't work. Has anyone had an exception request denied that was for a legit situation. This is a new,effective and expensive Pain RX that cost about $675/ month with without the side effects we all know. I didn't review all of the other plans but finding Humana not having this expensive RX on the formulary seems to be saying, "Please don't pick me." Now why in the world would they want to do that? HA!

BTW. I discovered something about this Rx that I had not heard of before, to help control the selling of this drug... It is in a sub-lingual form, that also has a specific number printed on each dose linked back to the patient. Pretty cool way to deter distribution.

 

[eharriett]

In our experience, whether it is an exception for a PDP or an MA, there's no guarantee of acceptance, regardless of company. That's a big "beware" sign on our chest when that comes up. You gotta find a different company that will guarantee to cover it, if possible. If not, make darn sure they know it going in. Assist them with help filing for the exception, if you desire. We do, every time we're asked. But for pete's sake, make sure they know the exception is **not** guaranteed.

And take care of that fact finding before the sale, if you can. This is why we frown on saying "take ABC company, it's all you need" for MA or PDP plans. You've gotta have several, and this is one of the biggest reasons.

 

[Aksarben68022]

I have had an exception request denied and it was a legit reason to request the exception. The client had been on a medication for years to treat a condition for which no other medications had worked and when he switched to a new MAPD they denied his medication we made an exception request with the doctors letter etc. detailing that no others meds worked and they still said no, luckily it was when there was still and OEP after Jan 1st so he was able to switch back.