When the Part D insurer goes the “extra step” to deny pt their medications

I got a phone call this week, a pt that has a Part D program, that is owned by a FOR PROFIT CORPORATION… that just owns about 10,000 community pharmacies, PBM Caremark, Aetna  Insurance and Silver Scripts Part D.

I would label this pt as a high acuity, intractable chronic pain pt with two very “painful” health issues.  The Part D didn’t want to pay for the medication that has been working for the pt, but had THREE PREFERRED MEDS – one of the meds the pt even had a health issue that would make one of their contraindicated for the pt…  and the other two the pt had tried before and either they didn’t work well and/or the pt was allergic to the med.

The pt found out that the employee of Caremark who made the decision to deny the medication that the pt had clinical proof that it work for the pt and the employee was a RETIRED PHYSICIAN… who was a GP or FP… no real experience with any experience with the two very painful diseases that the pt was dealing with… of course, this physician consultant … followed the Part D policy to recommend what appeared to be the three meds that cost the Part D the LEAST…

Of course, the pt’s physician appealed the denial and resulted in a rather quick repeat denial… and the pt & the physician wanted to appeal the first appeal and the pt was told that the Part D had done two more appeals on the pt’s behalf and those two other appeals were ALSO DENIED !!!

The pt was informed that the Part D allowed 3 appeals on the original denial of the claim, to the Part D was done with her claim.

I have read stories about these retired physicians that do Medical reviews for insurance companies … get BONUSES based on the $$$ that their decisions have saved the insurance companies.

This pt and/or the Physician was pretty well versed and had already tied to initiate a ALJ ( Administrative Law Judge) appeal and was told that there was no way that they could get an expedited ALJ hearing…  I don’t remember how long a back log there was, but apparently the pt may end up without their necessary medication.

Pts who find themselves in a similar position – playing games with the FOR PROFIT PART D and/or MEDICARE ADVANTAGE (part c) There is a potential option, especially for those pts with Regular Medicare.  If a pt’s prescriber requests a ambulatory  pain pump,  Our independent pharmacy  use to be a fairly large Home Medical Equipment vendor and unless they changed the rules… Pump are paid for by Medicare Part B and when Part B pays for such/similar equipment, Part B pays for the medication that goes in the pump.

Medicare Part B guidelines to cover HME stuff is pretty black/white guidelines, nothing like the somewhat arbitrary coverage of Part D and/or Medicare Advantage.  Besides all this, using a ambulatory pump… will allow the pt to get as good or better pain management than taking oral meds and because the medication is administered as a Sub-Q injection… the pt will need only 20%- 30% of the mgs that the pt took orally.  To the best of my knowledge, the CDC guidelines only address oral meds.

If anyone is interested in looking into ambulatory pumps… so a web search for “ambulatory pain pumps” and/or “diabetic insulin pump”… and I would do a search in U-tube as well..  The ambulatory pain pump and diabetic insulin pump are very similar pieces of equipment… and millions of diabetics uses these insulin pumps and have been using them for at least 15 yrs.


Leave a Reply

Discover more from PHARMACIST STEVE

Subscribe now to keep reading and get access to the full archive.

Continue reading