Step Therapy on PDP's, Your Experiences

[yorkriver1]

Some PDP's list certain Tier 3 & 4 drugs as Step Therapy. I am relatively new to writing more volume in PDP's/MAPD's.

I am concerned about suggesting a plan with step therapy, to save, say, $50/100 a year--or even more, and then have them go through a big hassle with step therapy, getting approval to just take the drug they were prescribed if it's working.

Bonus comment: This year it seems there are big differences in the results I am getting for plan comparisons on Medicare.gov, from the company sites, particularly for the Humana plans.
Anyone have suggestions for best practices on plan comparisons? I need a method that is the most accurate/least time consuming.

 

[G.Gordon]

We rarely suggest a change for less than $150/year and if there is a ST restriction one had best call the new plan for clarification on what is required. If they "think" it may have been satisfied in their medical history, then proceed, I'd be careful making someone change their healthcare regiment over a few dollars in savings with understanding the full implications.

 

[yorkriver1]

Thanks. Don't want to put them through the wringer.
They most likely need to change the plan they have now, First Health D, to get a more competitive one for this year. 2 of the 3 lowest cost plans for 2014 don't require step therapy.

If I don't spend the time to be an agent for one or the other of the 2, then I'll just send them there. May not be worth it for time/money. One of the competitive ones is Cigna and I am also signing up for their MedSupp.

One more pathway, they may qualify for help with that drug from the drug company. Giving them the info. on drug co. help from Medicare.gov first. Otherwise, their 3 generics are free through Humana mail order.

I don't get why Medicare.gov doesn't show costs as $0 for mail order for Humana for the Tier 1 and 2 generics. I also don't get why the .gov site shows a monthly cost when indicating quarterly mail order. I feel like I need a tutorial on using these calculators.

 

[G.Gordon]

We do pdp review totally as a client service item to make them stick with us and refer us to others. It works. We pick up several this time of year due to the activity. At the same time, we are careful not to over suggest or make minor savings such a big deal that they move plans. It can come back and bite you in the arse as quickly as it can help you. We NEVER suggest a "preferred" pharmacy over the local home town shop, we did that they first year First Health Value Plus came out, several took our lead and moved to WalMart to save several hundred to over a grand in the savings. That savings on paper goes away real quick when they are waiting on their meds 3 hours at Wally World, or they drop off 3, call to check, come back and have one ready. We had mad clients on that move. NEVER again. I view the pharmacist as part of their healthcare and I do not suggest someone change their healthcare regiment.

 

[yorkriver1]

Thanks for info. Really good advice from your experience. This is all a learning curve. Yes, all the painful experiences are great teachers. I learned in my earlier years in P&C where to step in and where to step back. Hate those phone calls, "You said"....
This forum is a huge help for me as an independent in life/health.

I have two new clients with some more complicated situations who I am going to contact to offer to help get through their new RX coverage smoothly. One has a drug that could be Medicare B or D. I will call the carrier to see what is needed to get that straight. The health conditions are pretty serious. I really want to work hard to assist these people. One may refer her dad for SNP MAPD. Aside from being the right thing to do, I look at it as an opportunity also to gain real world experience that will help me with others.