Drug Not Covered

[WIHealthAgent]

I recently had an application through Anthem in WI approved and issued at a 50% rate up. I got a call from the customer today because one of the drugs they had listed on the app for Migraines is not covered because it's an anti-depressant that is sometimes used to treat Migraines. Needless to say, it is a $200 per month drug and the customer is not happy. What if anything could I have done different up front, and what if any options do I have with this customer (she's been declined by pretty much everyone else already). She came of a Cinergy mini-med plan (that no longer is available in WI) and claims she got some sort of coverage for the drug their, but I can't believe it was much.

 

[Dave020]

If the medication is not FDA-approved for the treatment of migraines, they will not cover it. Carriers do not cover medications used for treatment purposes not approved by FDA.

If the medication is approved for migrane treatment by the FDA, you need to verify whether or not it is in formulary and/or if not doesi the plan have tier 3 non-formulary brand drug coverage level (some of the newer Anthem plans have tier 3 coverage now).

If the physician is a participating provider, the physician can talk to Wellpoint about the medication and try to get an approval for the use. Anthem membership will always tell the subscriber that there is no appeals process, but this is false. The provider can make request for coverage of the medication based on medical necessity so long as it is an approved medication for the treatment of that condition. It's not 100%, but works more often than not.

 

[DS4]

I got a call from the customer today because one of the drugs they had listed on the app for Migraines is not covered because it's an anti-depressant that is sometimes used to treat Migraines.

So the reason the Rx was declined was because of 1) off label use, or, 2) not on the formulary?

How did the Rx claim get processed? 1)electronically through a pharmacy?, or, 2) paper claim form sent directly Anthem?

 

[stuy119]

Canadian Pharmacy Online - Canada Pharmacy - Discount Prescription Drugs - CanadaDrugs.com

You're welcome.

 

[WIHealthAgent]

Thanks for the help all... What do you guys do to pre-screen for something like this before doing the app, or do you just take your chances?

 

[somarco]

Canada Pharmacy Online - Canada Pharmacy - Canadian Drugs - PharmacyChecker & CIPA Approved

I pre-screen almost everything.

 

[DS4]

B4 this thread dies, answer my questions above.

 

[arnguy]

Not to worry. Some newby will bring it back in about two years.

 

[ksigmtsu]

Thanks for the help all... What do you guys do to pre-screen for something like this before doing the app, or do you just take your chances?

I prescreen every client vs the uw field guide for all carriers before I place a policy, I find that most carriers are close to what the field guide says they'll do, with exception of bluecross.

If the case is multiple factors, I use all the uw prescreen tools available for carriers that have decent underwriting for the issues the client has.

I quote all my rates with anticipated rate increases already in the quotes, puts my acceptance rate a lot higher.

 

[Fisher]

or do you just take your chances?

I do everything humanly possible to prevent chances.