Non-formulary meds consistently denied by plan via appeal process?

Spud

Expert
Hi, are you aware of any plans/companies that consistently (have a policy?) to deny all appeals for coverage of a prescription med (on the CMS formulary but not on the plan's formulary)?
 
It’s my opinion that if you are persistent in this, you will get the approval. It’s my experience that people give up too easily. When you get past the first level of appeals, the carrier has to justify a denial to Medicare. Some docs aren’t willing to detail the need and step therapy.
 
If not on the formulary why should the insurance cover it? There is a reason it is not on the formulary. If you are running into this might want to check out alternate sources of getting the medicine, like goodrx or Canadian pharmacy, that also eliminates the need for jumping through hoops on appeals, prior authorization. Then make sure all meds are on the formulary for 2019
 
med's can be prescribed during the plan year (after plan selection)...this is the issue. the alternatives like good rx, blink health, etc are known. the issue is there is a defined appeal process and the goal of the thread is to identify companies/plans that have a consistent policy of saying 'no' to appeals (go to mexico, Canada, goodrx, etc).
 
med's can be prescribed during the plan year (after plan selection)...this is the issue.
I get that, but should be one off situation. I rarely have this issue come up. I usually discuss with the client that every drug plan has to cover at minimum 2 drugs in every therapeutic category, most cover quite a few. What is the medicine? Is it a pain medicine? Those are usually the medicines that PDP companies don't budge on formulary exception.
 
I get that, but should be one off situation. I rarely have this issue come up. I usually discuss with the client that every drug plan has to cover at minimum 2 drugs in every therapeutic category, most cover quite a few. What is the medicine? Is it a pain medicine? Those are usually the medicines that PDP companies don't budge on formulary exception.

I have had good success with appeals in this matter, However, its always a case where the alternative's were tried and did not work, Or had a bad effect, Ther has to be a good reason,

They are usually approved at tier 4 and we end up switching next AEP
 
After a few years selling Part D and MAPDs, I read the boilerplate in the front of the Part D brochure. D’oh! The plans are required by law to provide a maintenance med you’ve been taking for the first 30 days on the plan, while your Doc works on finding something in the formulary that will do.

This is only anecdotal, but if you’re willing to be a big enough PITA, they’ll pay for things they’re really not sposed to, just to get Medicare’s spotlight off ‘em.
 
Thanks for all of your comments. The reason the question was brought up is during aep product training the area mgr of one of the major pdp vendors said 'no' to the question...company policy. Just wondered if anyone was aware of other companies that have the same policy. I am asking the same question to the presenters at the other 2019 f2f broker training.
 

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