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Okay so we all know there is not one insurance company that covers every single drug in their formulary. We also know that if the doctor requests and signs off on a special approval form, a client can get his/her medication.
For example, one of my carriers does not have Lipitor; a doctor, however, signed off on the special approval form and the carrier added it to the forumulary for this client. Now this client can get lipitor. I know a lot of the decision making process by the carrier is what the doctor writes on this form , ie - patient needs it to sufficiently be well, etc. etc.
I also know that a company can say, "well, have her/him try this generic or preferred first and if that doesn't work, then well add Lipitor (in this example) to our formulary for him/her.
Here's what I want to know and I'm hoping one of you professional agents can answer my question listed below.
Can an Rx Company refuse a special approval form even if the doctor writes life threatening or something other that is needed for the client/patient to get his/her meds? Legally, do beneficiaries have the right to get their drugs no matter what?
For example, one of my carriers does not have Lipitor; a doctor, however, signed off on the special approval form and the carrier added it to the forumulary for this client. Now this client can get lipitor. I know a lot of the decision making process by the carrier is what the doctor writes on this form , ie - patient needs it to sufficiently be well, etc. etc.
I also know that a company can say, "well, have her/him try this generic or preferred first and if that doesn't work, then well add Lipitor (in this example) to our formulary for him/her.
Here's what I want to know and I'm hoping one of you professional agents can answer my question listed below.
Can an Rx Company refuse a special approval form even if the doctor writes life threatening or something other that is needed for the client/patient to get his/her meds? Legally, do beneficiaries have the right to get their drugs no matter what?