i have a prospect who is interested in an hmo with Optimum health. But her insulin isn't covered on the formulary. I doubt that Optimum would make an exception for a prospect. But what is the likelihood they would allow her to take this drug, and cover it, if she becomes a member and makes that request? I haven't made a formulation request yet. if you've had experience, please let me know. Thanks!
likelihood of drug being added to formulary?
- Thread starter keith365
- Start date
StephanieCJ
Guru
- 660
Depends on the insulin. Humalog to Novolog doesn't seem to be an issue for docs. Most clients have been on either one at different times if insulin dependent. Some of the others are pretty specific. I would try to find a plan that covers the medications as it first. If that isn't an option, have the client call their doctors office about the possibility of switching the med. Formulary exceptions haven't tended to be a huge issue on MAPD, but I would not sell a plan based on that.
Have you ever seen a plan agree to a formulary exception for someone that is not a policyhholder? IOW, would they agree to the change for someone who MIGHT enroll IF the exception was made?
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