1 Help! I Couldnt Get My Prescription Filled: Whats Going On and What Can I Do About It? Health Action 2006 Health Assistance Partnership January 28, 2006

2 Why Do Part D Plans Deny Coverage? Utilization management tools Prior approval Step therapy Therapeutic substitution Quantity limits Plan decides medication is not medically necessary

3 Why Do Part D Plans Deny Coverage? (cont.) Prescribed medication is not on the plans formulary (drug never on formulary or removed from formulary) Prescribed medication is not a Part D- covered drug Enrollee goes to the wrong pharmacy

4 Action Steps When Part D Plans Deny Coverage Ask plan why the drug was denied coverage Talk to prescriber about alternative drugs that are on the plans formulary Ask the prescribing doctor to adhere to plan rules about utilization management tools Seek a formulary exception from the plan

5 When Can Enrollees Request a Formulary Exception? If they are taking: a non formulary drug or a dosage form and/or amount that is not on the formulary a drug with a utilization management tool a drug that is removed from the formulary mid year a unique medication But, one cannot get a exceptions for both formulary and cost-sharing

6 Requesting an Exception (cont.) If they cannot afford the cost sharing amount. But, if plan has tier for generics, cannot get exception to reduce copay of brand names to the generic level. If enrollees have mid-year change in drug regime and are prescribed a drug: that is not on the plans formulary with a utilization management tool with cost-sharing that the beneficiary cannot afford If enrollee cannot take an alternative drug on plan s formulary, he can request a formulary exception.

7 When Enrollees Cannot Request an Exception If enrollee is currently taking or newly prescribed an excluded Part D drug If enrollee goes to the wrong pharmacy Pharmacy not in plans network- no refund for out-of-network price difference Not preferred pharmacy- no refund for non- preferred price difference

8 Exceptions Process (cont.) Who can request the formulary exception? Enrollee Prescribing physician Authorized representative (i.e. guardian, health care proxy) Appointed representative Must complete an appointment of representative form and submit it with each request

9 Exceptions Process (cont.) What role does the prescribing physician play? Must submit a written statement to the plan stating that: none of the drugs used to treat the patients condition in the plans formulary would be as effective in treating the patient, and/or all of the drugs in the plans formulary for the patients condition would have adverse effects

10 Exceptions Process (cont.) Plan must notify enrollee of coverage determination or formulary exception within 72 hours Expedited requests are decided in 24 hours Mandatory if physician makes request to expedite Plan must forward the request to an Independent Review Entity (IRE) if it cannot meet the 72 hour deadline

11 Exceptions Process (cont.) Plans that approve exception for non-formulary drugs cannot assign them to a special tier Formulary exception lasts for rest of plan year Plan sponsors can develop process for notifying enrollees of any continued coverage after end of plan year Enrollees may be required to submit new exception for following year

12 Appeals Process If enrollee is denied formulary exception or coverage determination by plan, she can appeal: Redetermination by plan Reconsideration by Independent Review Entity Review by Administrative Law Judge Amount in dispute must be at least $ Review by Medicare Appeals Council Review by Federal District Court Amount in dispute must be at least $1,050.00

13 Health Assistance Partnership Kelly Brantley Lee Thompson