I ordered atorvastatin (generic Lipitor) for one of my patients with high cholesterol and Medicare Part D coverage. It was denied. We then appealed it (prior authorization). A fax from Maximus Federal Services said their decision was, “UNFAVORABLE.” They said the patient had not tried and failed one of the preferred generic statins (lovastatin or simvastatin). They did note that we could appeal to an Administrative Law Judge.
In fact the person had tried simvastatin, which I had noted on the prior authorization. However the cost savings is minor. According to Goodrx, a 90 day supply of atorvastatin is as low as $19.25 around where I work. For the equivalent dose of simvastatin it’s $10.06.
Yes, it’s almost half the price, but it’s still a pretty small amount, especially in my patient who had already had a heart attack, and the difference will only get smaller as Lipitor has not been generic for all that long. Contrast that with the staff time wasted dealing with this on both ends. Dealing with this is a pain in the Gluteus Maximus!
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Clearly a pain in the rear. They (claims process) hope you won’t go to the Administrative Law Judge. I’d suggest they to go to that appeal. It might be helpful for them to have you or your PA attend.
I don’t have a PA (physician assistant, as opposed to prior authorization), and they would not reimburse me for attending. I’d lose hundreds of dollars blocking out my schedule arguing over a $10/month difference in cost.
That’s exactly their plan; i.e., deny, deny because many will not pursue. They “bank” on people accepting denials at 1st and 2nd levels (sometimes 3rd). Insurance companies learned this strategy from the government; both deep pockets, but the government can just print money while denying and denying. It’s been going on for decades. So, your time and money vs. theirs. If this is a non profit you work for, perhaps they should make an administrative “policy” decision and “have your back, paying for your “battle”; isn’t it their battle too or are they not aligned with you? If not, why not? On the other hand, I guess there are many battles; have to pick which ones you are aligned with. What would a private practice do? My 25 cents opinion.