Medicare - Medicaid - Medicare Advantage

[policywunk]

Last dual prospect I couldn't sell in good conscience. Two meds weren't covered by every plan in the service area and they weren't cheap. I won't risk my reputation on a carrier approving an Rx. Lost two plus hours on the appointment and subsequent communications, but she will hopefully remember me when her DNSP friends want coverage.

Did you see if they were even covered on her current PDP plan or covered by any medicare part D at all? Usually when i run in to this it is either it's not a medicare covered drug or they got a formulary exception for it on current plan. The DSNP part D formulary are usually better than the stand alone PDP plans they give to dual eligibles and also I can't remember the last time a DSNP member asked for a formulary exception and didn't get one. Recently i had a member who insisted she had to have the brand name ( was currently getting an exception on PDP for drug)that cost about 1200.00 even though there is generic available and UHC approved it.

 

[AgentGeneral]

Did you see if they were even covered on her current PDP plan or covered by any medicare part D at all? Usually when i run in to this it is either it's not a medicare covered drug or they got a formulary exception for it on current plan. The DSNP part D formulary are usually better than the stand alone PDP plans they give to dual eligibles and also I can't remember the last time a DSNP member asked for a formulary exception and didn't get one. Recently i had a member who insisted she had to have the brand name ( was currently getting an exception on PDP for drug)that cost about 1200.00 even though there is generic available and UHC approved it.

Yep, same Some of the ER Rxs too cost more and aren't on formulary , but they approve them anyway and quite quickly. Just one more fyi thing I noticed.

I do have one right now I'm waiting on bc of meds. Even though there is a transition policy to cover meds not on formulary. Im a little skeptical on a few. Specifically I have a young man who is on Haldol and Clozapine (kind of old school meds not often prescribed anymore), not on formulary. This one I'm not sure on. There aren't identical structured meds that I'm aware of on formulary and I can't be certain it would be an accepted exception.

I do walk away from my fair share for whatever reason. I have a few on hold for different reasons right now.

I agree family man, wouldn't risk my reputation. One deal will never make or break anyone.

Side note: I was amazed at how personalized a few of the carriers make it for the client. I guess those health care assessments we do, you know, to get paid more aren't just for extra pay for us lol To me it can be very well managed care, not "mangled" if it's done properly. Ex: Clients who get help with wigs for after cancer treatment, weight loss management, dietary/nutrition help, more easy access to DME, and transportation and house cleaning help, pest control, and the list goes on and on. Way more than just the food cards and what not hmmmmmm. yah these plans sure do suck sighhhhh they certainly don't help with quality of living now do they- eyeroll

 

[somarco]

Haldol and clozapine are inexpensive generics . . . think outside the box and use SingleCare, GoodRx, etc

 

[AgentGeneral]

Haldol and clozapine are inexpensive generics . . . think outside the box and use SingleCare, GoodRx, etc

Already thought of that. Thanks

His issues worry me. He will undoubtedly be pushed around on one med after another. Schizophrenia - the resistant kind. PITA. 4 hospitalizations in past 3 yrs. Bounced on all types of meds landing on the haldol/clozapine and being weaned off that to go on Invega which will be easier but will that last. No it won't. For now he stays put without the DSNP.

Question though. if they have insurance, can they still use the GoodRx? Hows that work? I cant remember what I learned on that? As I rant on having to help an elderly agent, I can't remember some things either. I think they can use it but can't remember. I think it's the coupons they can't use. Hell idk. my brain isn't working today. It's my day off, which is why I'm playing in here for a minute. G daughter coming over and we are off to the beach soon. Single care? that one I haven't thought of...

Thank you

 

[somarco]

https://www.singlecare.com/ https://www.goodrx.com/ . . . either can be used in place of PDP but not in conjunction . . . no double discounts.

Over half my clients are on the $7 SilverScript plan and never use it. They use a discount card for generics and sometimes https://www.mapleleafmeds.com/ for brand names. Some brands are available in generic form from Canada as well.

Cross check Grx with SingleCare . . . depending on the pharmacy and the med, sometimes SC has a lower price than Grx.

Also, some pharm's have their own "club" with discounts lower than coupons. We use Publix for the 2 med's my wife uses and the Publix 90 day supply is sometimes less or just a few $$ more than 30 days with SilverScript.

For a few clients PDP is a necessary evil but all are encouraged to shop around for generics.

 

[AgentGeneral]

https://www.singlecare.com/ https://www.goodrx.com/ . . . either can be used in place of PDP but not in conjunction . . . no double discounts.

Over half my clients are on the $7 SilverScript plan and never use it. They use a discount card for generics and sometimes https://www.mapleleafmeds.com/ for brand names. Some brands are available in generic form from Canada as well.

Cross check Grx with SingleCare . . . depending on the pharmacy and the med, sometimes SC has a lower price than Grx.

Also, some pharm's have their own "club" with discounts lower than coupons. We use Publix for the 2 med's my wife uses and the Publix 90 day supply is sometimes less or just a few $$ more than 30 days with SilverScript.

For a few clients PDP is a necessary evil but all are encouraged to shop around for generics.

Thank you! Cleared that up well for me. Had a brain gap.

I guess I did know that as I sent a lady to get one of her meds with Good Rx (non DSNP). Forgot about that one. It wasn't a med she was on when I enrolled her. Didn't know about SC so thats something I will check out. On the above example That guy gets Haldol as an injection in a doc office by a NP, prob bc of his Dx, twice a month for now. I'm not even sure now if it'd be considered Part B or what since it's admin'd by a NP at doc office. Just says, "most meds in facility....are Part B" on what I was reading online.

Shelving this one for now. At least until his doc gets him off that drug and onto Invega which will also be an injection that is on formulary. No hurry bc he's covered fine now.

Thanks again

 

[somarco]

That guy gets Haldol as an injection in a doc office by a NP, prob bc of his Dx, twice a month for now. I'm not even sure now if it'd be considered Part B or what since it's admin'd by a NP at doc office

I noticed Haldol was an ampule and wondered if it was administered in a clinical setting then it is Part B and doesn't need to be on the formulary. Same for the NP who gives it to him. Look at it like a vax (which used to be given in a docs office before pharmacists could administer them).



Haloperidol treats schizophrenia and manages tics and vocal outbursts if you’re diagnosed with Tourette's syndrome. It can also treat behavioral issues among children. This medication comes in a tablet form that you can take by mouth with a glass of water as directed. The brand name of haloperidol is Haldol®.
[EXTERNAL LINK] - Haloperidol (Haldol): Uses & Side Effects | Cleveland Clinic

 

[rmhaire]

I noticed Haldol was an ampule and wondered if it was administered in a clinical setting then it is Part B and doesn't need to be on the formulary. Same for the NP who gives it to him. Look at it like a vax (which used to be given in a docs office before pharmacists could administer them).



Haloperidol treats schizophrenia and manages tics and vocal outbursts if you’re diagnosed with Tourette's syndrome. It can also treat behavioral issues among children. This medication comes in a tablet form that you can take by mouth with a glass of water as directed. The brand name of haloperidol is Haldol®.
[EXTERNAL LINK] - Haloperidol (Haldol): Uses & Side Effects | Cleveland Clinic

Also prescribed for stage 2 Alzheimer's patients.

 

[AgentGeneral]

Also prescribed for stage 2 Alzheimer's patients.

Oh cool didn't know that. also good to know. it's schizophrenia in this case. And holy hell, they give that to kids? That stuff would knock a horse out.

 

[Family Man]

Seems weird, was it covered by her pdp?

What were the drugs? I have never run into a situation where a medication wasn’t covered by any plan.

I don't recall the Rx, but they weren't covered by any medicare rx plan or MA formularies. She is T65, so she paid a deductible with her obamacare plan and wasn't paying for the meds after that. Not sure why those crappy plans cover meds that medicare plans do not.