Quantity Limits, Step Therapy and Prior Authorization

Sep 23, 2015

  1. Justin Bilyj
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    Justin Bilyj Guru

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    I didn't see a thread about this and was wondering what your interactions with these 3 moving pieces and parts to Part D Plans was. Do you find a particular carrier who likes to use these for a lost cost plan?

    Do you find your clients could care less about these three issues when examining their total out of pocket costs for the year?
     
  2. G.Gordon
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    1. When plans are close in annual plan cost we look at restrictions as a decision maker. AARP has been the leader so far for low restrictions usage.

    2. Step therapy can be a doozy, make sure they have been on the ST drug before, punting them to a plan with ST, then having them try the drug after the first of the year to transition back to the drug they were on is a PITA.

    3. Quantity limits are not an issue most of the time. I've seen less than a half dozen times it bit a client in the butt. Three of those were Nexium at 2x daily, QL is always 30/month.

    4. PA can be a PITA if you get a moron provider that is having a bad day and thinks, "Because I'm the doctor" is a good enough reason for authorization of a frequently abused drug.
     
    G.Gordon, Sep 23, 2015
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  3. Justin Bilyj
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    Great Post! Was wondering if you can find out ahead of time what the ST drug would be. Can a pdp member ask their doctor to make an exception to a ST drug?
     
  4. G.Gordon
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    Yes, if you click on the ST on m.gov it should bring up that information. Caution: Just because they used the medication listed as the ST, the other requirements can be just as sticky. For example, Metformin 1000mg 2x daily for x days, they might have only used 500mg 2x and only for 60 days.
     
    G.Gordon, Sep 23, 2015
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  5. Justin Bilyj
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    are you referring to quantity limits, sorry didn't understand that last sentence.
     
  6. G.Gordon
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    NO, ST can have not only a required drug, but that the drug be taken in a required strength for a specific time period. Safety and patient therapeutic results can trump the time requirement. Say a person was taking the metformin at the required dose, but broke out in hives or their therapeutic results were not being achieved, they are in danger by staying on the medication any longer and their doctor will prescribe something else (like the ST drug). If that information is shared during the ST authorization from the provider it is cleared most of the time.
     
    G.Gordon, Sep 23, 2015
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  7. sman
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    This pretty much sums it up. However, I've had two clients this year have issues with AARP on PA. The medication is Androgel. AARP denied both of them initially. I guess it's possible that the doctor did the whole, "because I said so" thing. But they both had to end up filing an appeal with Medicare and finally got it approved. They both also had to go one month without the medication. And both have said, "I don't care if I have to pay more next year, I don't want AARP and I don't want to deal with PA".

    As for Gordon's first point, this is exactly how I look at it as well. And virtually all my clients have no issues after I explain it to them. They all want the least amount of hassle and are willing to spend a little extra money.

    This next part is for you Justin and anyone else new to Part D, you are going to have clients who after changing their plan will call you and say something like,

    "I just got my prescription filled and had to pay $XX. Last year I only paid $XX. Why did we change my plan if I have to pay more now."

    This is where having the copy of the comparison comes in handy. Not that you couldn't explain it to them, but being able to show them in black and white is extremely helpful.

    "Mrs. Jones, the plan you were on last year changed it's costs for this year. Had you stayed on that plan you would spent $XX for the year. On this new plan you'll save $XX over the course of the year compared to last year's plan. Remember, these carriers change their plans from year to year and just because a plan was the lowest cost one year doesn't mean it will be the lowest cost plan the next year. That's why we do these comparisons each year to make sure we are saving you the most money possible"

    Then you usually get, oh ok, I remember now. I don't get a ton of these calls because I try and cover that really well at the time of the change, but it still happens from time to time.
     
    sman, Sep 23, 2015
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