Cimzia, PDP and PAP's

[somarco]

New client, takes Cimzia injectable for Crohn's. Out of 30 or so PDP's in his area only 3 include Cimzia.

Month supply $7948 retail, $2675 on formulary.

PAP for Cimzia says no to coupon if you have a PDP.

Not valid for prescriptions that are reimbursed, in whole or in part, under Medicare (including Medicare Part D)

If he bought a PDP that did not include Cimzia on their formulary could he qualify for the PAP?

Have you ever had a client who did something like this with any drug?

 

[vic120]

Maybe this will help
https://metromedicalorder.com/_reso...6472-1013 MM Coverage Notice Letter_final.pdf

 

[DS4]

https://www.medicare.gov/pharmaceutical-assistance-program/index.aspx?drug_id=12604#

Click on the letter "C". Locate Cimzia

 

[kstein]

I have a couple clients at take this drug for rheumatoid arthritis and it is covered by Part B. They go do an injection infusion center once a month.

 

[somarco]

Thanks.

This guy has Chrohn's. Self injected at home.

The link provided by Vic seems to indicate it is only covered by B if the drug is in powder form to be reconstituted. Not sure that is the case here.

Dayton, will pass this along. His income may KO him.

Great links. Thanks guys.

 

[somarco]

Vic, a couple of questions.

How did you find that link showing Part B drugs? Have you had success getting the drug approved for Part B? Any trouble finding pharmacies willing to fill under Part B?

 

[vic120]

Vic, a couple of questions.

How did you find that link showing Part B drugs? Have you had success getting the drug approved for Part B? Any trouble finding pharmacies willing to fill under Part B?

I just found that link online

As far as Getting part B drugs covered depends on the area, Some area's are completive bidding area's so on Medicare.gov you can find approved Pharmacies and medical supply that are listed to be used, I have a case now I am working on, The Guy uses Tyvaso for nebulizer, This I have found will be covered By part B but has to use an approved medical supply in competitive bidding and has to be coded correctly, When I called Medicare they told me they will check code for me to be sure, I am waiting on code now

I have not had too many issues with part B drugs and I have a few that use part B, I have a lady who had kidney transplant and has her meds covered, But I was not too involved with getting it covered

I have had a few issues with diabetic supplies few pharmacies will make them pay towards part B deductible even when they have F and get reimbursed

I also have had some that wont bill part B for supplies in those cases I have them use medical supply place

 

[somarco]

Thanks again.

I could have PM'd you but figured I would keep it public so others can benefit.

I sent info to him today, along with coding info from a Cahaba link. Cahaba is the Medicare TPA for Georgia so followed the link you had to Cahaba. That's where I got the coding. You might do the same for your situation, except obviously use the appropriate TPA for your client's state.

Client is taking the info from the link to his doc tomorrow to see what they can work out.