PDP question: 2025 renewal--is annual prior authorization required for a drug that has been approved in 2024

[yorkriver1]

The client could save some money by switching from the lower cost PDP to the more expensive/lower deductible PDP in the same company, but is concerned about needing to do prior authorization. No one has asked me before if prior authorization carries over assuming the drug is still in the formulary, year on year or if prior auth has to be re-authorized each plan year.

 

[Fisher]

Call the company. I would plan on PA being needed again, though.

 

[somarco]

Assume nothing.

Formulary changes, smaller pharmacy footprints and prior authorization rules all changed for 2025. It's almost required reading to look through the SOB before suggesting a plan.

Just today I had two clients ask for a copy of the pharm network and I can't ever recall having that come up before.

 

[goillini52]

Assume nothing.

Formulary changes, smaller pharmacy footprints and prior authorization rules all changed for 2025. It's almost required reading to look through the SOB before suggesting a plan.

Just today I had two clients ask for a copy of the pharm network and I can't ever recall having that come up before.

UHC hasn't even published their 2025 Formularies yet. How can they get away with that?

 

[hockeyday]

The client could save some money by switching from the lower cost PDP to the more expensive/lower deductible PDP in the same company, but is concerned about needing to do prior authorization. No one has asked me before if prior authorization carries over assuming the drug is still in the formulary, year on year or if prior auth has to be re-authorized each plan year.

Will needto be redone

 

[just-a-client]

UHC hasn't even published their 2025 Formularies yet. How can they get away with that?

Here's one of the formularies. Updated in October. I presume the other plan is there too. It's a weird url but it's a pdf. I just searched for unitedHealthcare part D and then picked 2025.

https://www.uhc.com/medicare/alphadog/PDEX25PD0255336_001

With WellCare value script, a prior auth I got one year automatically carried over indefinitely. In fact the letter of approval they sent showed that there was no expiration date.

They told me that prior auth doesn't expire but that tier exceptions are only good for one year at a time.

However, I was staying in the same plan, and even so, I doubted them until I refilled in January and it went through without a hitch. It wouldn't be surprising if you had to start over with prior auth if you changed plans. But since they are using the same Pharmacy benefit manager and it's the same company, it also wouldn't be surprising if the authorization remained in force. Better to call and get an answer and assume the worst.

It always seems to me that during the annual election period one should be able to get authorizations for the following year – if the authorization is denied then you'd have the opportunity to consider other plans before December 7. That would be rational, so maybe some plans do allow it?

 

[annon123]

It always seems to me that during the annual election period one should be able to get authorizations for the following year – if the authorization is denied then you'd have the opportunity to consider other plans before December 7. That would be rational, so maybe some plans do allow it?

You are assuming rationality... I wouldn't count on that in all cases

Likely they figure it is too much work for them to do it (and they are so many of them) when people, who haven't made their firm choice yet on a plan and can still change. Then they will shop that across policies before choosing. Certainly if all drug plans had a policy that all authorizations carried over that would help.

Or the morel unethical interpretation they don't want people to know and want them to assume nothing will change and then, when it is too late to do anything about it, they have a gotcha. Ching Ching. Of course some people still end up with a gotcha if the formulary changes in March.

 

[somarco]

Of course some people still end up with a gotcha if the formulary changes in Feb

Formularies change almost daily and are updated monthly. The copay you saw during AEP may be completely different the next time you refill.

Medicare Part D plans: Can change their formulary after the first 60 days of the year. Plans must give patients at least 60 days notice of changes that affect a drug they take.

Formularies can change during the year because of drug therapy changes, new drugs, or new medical information.