Part D and Formulary with special approvals from doctors

May 30, 2007

  1. honestagent
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    Okay so we all know there is not one insurance company that covers every single drug in their formulary. We also know that if the doctor requests and signs off on a special approval form, a client can get his/her medication.

    For example, one of my carriers does not have Lipitor; a doctor, however, signed off on the special approval form and the carrier added it to the forumulary for this client. Now this client can get lipitor. I know a lot of the decision making process by the carrier is what the doctor writes on this form , ie - patient needs it to sufficiently be well, etc. etc.

    I also know that a company can say, "well, have her/him try this generic or preferred first and if that doesn't work, then well add Lipitor (in this example) to our formulary for him/her.

    Here's what I want to know and I'm hoping one of you professional agents can answer my question listed below.

    Can an Rx Company refuse a special approval form even if the doctor writes life threatening or something other that is needed for the client/patient to get his/her meds? Legally, do beneficiaries have the right to get their drugs no matter what?
     
  2. GreenSky
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    From what I understand and from experience, an insurance company only has to have at least one drug in every class of medication.

    The fact that your carrier approved a non-formulary drug is either luck or an anomoly. My experience has not been a good as yours.

    The only company I know that doesn't cover Lipitor on their formulary is WellCare, but perhaps there are others. I always run the drugs on Medicare.gov first to make certain the client has coverage.

    You'll find that some companies require a step-therapy and others will not. It's worth the time to be "value added" to your clients.

    Rick
     
    GreenSky, May 30, 2007
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  3. midwestbroker
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    midwestbroker Guru

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    A client can usually get around step therapy with a note from the doctor.

    Adding a drug for use that is not on the formulary is a bit tougher, but with the right steps / greviences, I think it is poss. The carrier does reserve the right to decline such actions, and can offer a different drug in that class. If it was a life threating situation, I think the carrier would be more open to it. But I would not get my clients hopes up.
     
  4. honestagent
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    Sorry for the stupid question but what is: 'step therapy?'
     
  5. GreenSky
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    Step Therapy: You can have the medicine the doctor wants you to take but you have to try the cheaper one first. If it doesn't work, you can step up to the "real" thing.

    I do some research for my PDP clients by not only looking for a carrier who covers their medication, but if possible, a company that will not make the patient do backflips to get it.

    Rick
     
  6. honestagent
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    Thanks a lot Rick!
     
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