Drug Not on any Formulary

[somarco]

Vtama. New client on 3 meds for eczema . . . one affordable generic (clobetasol), one expensive generic (halcinonide) and one brand name (Vtama).

Halcinonide is tier 3 or 4, depending on the plan . . . also discounted with GRx or SingleCare, but still expensive. Halcinonide on a FEW formulary's but not cheap.

Vtama not on any formulary, INCLUDING MAPD (where the annual cost is $6k and up.

I still have a few other avenues to explore, but particularly interested in what the MAPD experts would suggest for your client.

 

[sshafran]

Vtama. New client on 3 meds for eczema . . . one affordable generic (clobetasol), one expensive generic (halcinonide) and one brand name (Vtama).

Halcinonide is tier 3 or 4, depending on the plan . . . also discounted with GRx or SingleCare, but still expensive. Halcinonide on a FEW formulary's but not cheap.

Vtama not on any formulary, INCLUDING MAPD (where the annual cost is $6k and up.

I still have a few other avenues to explore, but particularly interested in what the MAPD experts would suggest for your client.

I'm assuming you already did a search for patient assistance. That's usually about all you can do up front pre enrollment.

Once on a plan - try for *formulary exception.* I've seen fairly good results with that.

 

[Ashmeade]

MAPD/PDP both have options to petition a formulary change (either for coverage or tier status) for a med that is deemed medically necessary by a medical practitioner. Usually it'll be Tier 4/5 if it's expensive and not covered at all. It's up to the insurer and they will likely want some sort of proof other therapies were not effective.

Otherwise, some manufacturers offer some sort of patient assistance to Medicare beneficiaries. It depends on the med and the program. Some will make you spend a certain amount with your Part D/MAPD plan before they will help. They base this, from my general experience, on FPL from LIS level up to a determined threshold.

May also ask the manufacturer for any specialty pharmacies they can refer to. I've worked with some expensive creams where I found them dramatically cheaper depending on the pharmacy and it's negotiated amount.

 

[sshafran]

I'm assuming you already did a search for patient assistance. That's usually about all you can do up front pre enrollment.

Once on a plan - try for *formulary exception.* I've seen fairly good results with that.

For other agents out there - every plan has an Evidence of Coverage which outlines how to request formulary exceptions.

 

[somarco]

I'm assuming you already did a search for patient assistance.

Yes, PAN is only option for Vtama. Halcinonide does not have a PAP option but does have PAN.

Formulary exception is a consideration, but, as you noted, only for post-issue. I hope to get something from PAN before applying for a crazy expensive PDP and hope for a formulary exception.

MAPD/PDP both have options to petition a formulary change (either for coverage or tier status) for a med that is deemed medically necessary by a medical practitioner. Usually it'll be Tier 4/5 if it's expensive and not covered at all. It's up to the insurer and they will likely want some sort of proof other therapies were not effective.

Otherwise, some manufacturers offer some sort of patient assistance to Medicare beneficiaries. It depends on the med and the program. Some will make you spend a certain amount with your Part D/MAPD plan before they will help. They base this, from my general experience, on FPL from LIS level up to a determined threshold.

May also ask the manufacturer for any specialty pharmacies they can refer to. I've worked with some expensive creams where I found them dramatically cheaper depending on the pharmacy and it's negotiated amount.

Been there, done that, but thanks for the explanation . . . lurkers may benefit from this thread.

This lady has been battling eczema for over a dozen years. Tried different meds and changing docs. Also tried laser treatment with no improvement. Diet changes have not helped either.

Clobetasol (her other med) provides some relief but she has some persistent spots (including scalp) where she needs something stronger, hence the halcinomide and Vtama

PAN seems to be the last hope before taking the plunge on a PDP and hoping she isn't shot down.

 

[Ashmeade]

Yes, PAN is only option for Vtama. Halcinonide does not have a PAP option but does have PAN.

Formulary exception is a consideration, but, as you noted, only for post-issue. I hope to get something from PAN before applying for a crazy expensive PDP and hope for a formulary exception.



Been there, done that, but thanks for the explanation . . . lurkers may benefit from this thread.

This lady has been battling eczema for over a dozen years. Tried different meds and changing docs. Also tried laser treatment with no improvement. Diet changes have not helped either.

Clobetasol (her other med) provides some relief but she has some persistent spots (including scalp) where she needs something stronger, hence the halcinomide and Vtama

PAN seems to be the last hope before taking the plunge on a PDP and hoping she isn't shot down.

I figured. That’s about the most I can think of. I’m interested in further comments here. Sorry I wasn’t a help.

 

[LostDollar]

For the lurkers, when PAN is mentioned, is this it?

[EXTERNAL LINK] - PAN Foundation - Home

 

[somarco]

I figured. That’s about the most I can think of. I’m interested in further comments here. Sorry I wasn’t a help.

No worries, I appreciate the comments, from both you & Scott.

I was hoping for an option, maybe something I had missed. Also interested in comments from the MAPD whiz kids that say MAPD solves all problems, including Rx . . .

As stated, even if there aren't better options, at least lurkers may glean something from this thread.

 

[somarco]

For the lurkers, when PAN is mentioned, is this it?

[EXTERNAL LINK] - PAN Foundation - Home

Yes . . . thanks for the clarification.

Some folks may think of Peter (the boy who never grows up, not the peanut butter) but in this case it is the foundation.

 

[Patrick Flammia]

For the lurkers, when PAN is mentioned, is this it?

[EXTERNAL LINK] - PAN Foundation - Home

needymeds.org is what I use, type in the medication name, a list of available foundations will show up.