Any Experience Requesting a Formulary Exception?

[AllGold]

I have a potential client who is taking Inderal L.A. She has had problems with allergic reactions to the generic (Propranolol) so her doctor keeps her on the brand name.

The problem is out of the 33 PDPs and however many MAPDs available in her county, there is exactly one PDP and zero MAPDs with Inderal in the formulary. She has original Medicare and the one PDP now but would like to try an MAPD (LIS and can't afford a med supp).

I have no experience with requesting a formulary exception since in the past it has always been fairly easy to find other plans. Not this time.

How rough is the formulary exception road?

 

[tins]

I have helped a few clients with UHC because UHC generally doesn't cover the anxiety type meds (diazepam, lorazepam, etc). They had their doctor's office send in the reason they needed to be on those meds. Every time (I believe 5 or so times) it was approved by UHC. I've, also, heard from clients with other companies that have had to go through the same thing. Just about every time, the companies will approve.
It may be a little hassle, but in the end I don't think it'll be an issue.
Good luck, have fun.

 

[healther]

The only problem I have had was due to the doctor's office not having documentation of prescribing the generic in the past. In some cases this is required. Otherwise, I have had very few issues.

 

[supersupps]

No need to do formulary checks.. everything always gets approved, except oxy

 

[tins]

No need to do formulary checks.. everything always gets approved, except oxy

I tell them oxy won't be covered and to switch to straight morphine. Then I take their oxys and send 'em to Senior Advisor Indiana. He tells me that's what he pays his telemarketer with.

 

[eharriett]

Every year, we help a couple clients file for both formulary and tiering exceptions. The most important thing you can do is make sure your client understands that you CANNOT guarantee they'll get it. The only guarantees they have for coverage are those drugs on the formulary, and even then, the exceptions, if any, must be satisfied.

Get the forms from the plan's site, give it to the client, get the doctor involved. In my experience, the doctor's involvement tends to go a long way to making sure this gets covered. They've got as good a chance as anyone else to make this happen.