Medicare Part-D ... Any Off-Label Experiences?

[sengsational]

I'm shopping for Medicare Part-D plans and wondered if anyone had experience with getting off-label prescriptions covered. This obviously isn't worth exploring if you only use low-tier prescriptions, but if you're in the market for some tier 4 or 5, might be worth investigating.

According to this paper, "up to 1/3 of all prescriptions for common drugs in the US are off-label". Quite a surprising statistic, so I figured maybe someone here has experience with coverage under Medicare Part-D.

My first bit of investigation was to just call, as a shopper, a random plan: Aetna SilverScript SmartSaver. I asked if drugs that were prescribed "off-label" would be covered. The rep said it didn't matter...if the doctor prescribed it, it would be covered. That was too easy. I didn't believe the rep.

So I started looking at the summary plan description for that plan. It says:

Your drug must be used for a medically accepted indication. A “medically accepted indication” is a use of the drug that is either approved by the Food and Drug Administration or supported by certain reference books

and this

Our plan usually cannot cover off-label use. “Off-label use” is any use of the drug other than those indicated on a drug’s label as approved by the Food and Drug Administration.
? Coverage for “off-label use” is allowed only when the use is supported by certain references, such as the American Hospital Formulary Service Drug Information and the DRUGDEX Information System.

Those sources appear to be subscription based, so you can't just look up your drug there, unfortunately.

Anyway, the plan description is in direct conflict with what the rep said! I'm so surprised the rep was wrong .

The plan description then has several pages talking about "in-network pharmacies" (groan), and drugs requiring "prior authorization" (groan). But let's presume that can be worked out with some diligence.

And one thing that is easy to do is find out if the drug is covered (given the prescription is for an FDA approved indication). There must be a law that forces them to provide the list of drugs covered, because they all do it. Of course they can change the formulary without warning, but let's put that aside.

Then there's 8 pages in the document that describe how they handle exceptions and the 5 levels of appeal available.

So I just wondered if someone here has gone through the process of getting a high-tier, off-label prescription covered under their Part D plan.

Successes or failures?

 

[Gotadimple]

Off label means just that: the doctor is prescribing a drug not approved for use for the condition. The doctor is deciding using this drug may help the condition being treated. The drug is FDA approved and tested.
Tier 4 and 5 drugs aren't made in generic versions, or aren't widely prescribed. That doesn't mean they are off label. They are FDA approved and tested - just aren't cheap.

Your first link relates to whether or not a drug manufacturer can advertise for off-label use: no they can't, but a physician can prescribe a drug to help a condition for which it hasn't been tested or approved.

If you are taking a specific drug, I suggest you call Aetna Customer Service back and ask specifically about your prescription and whether that is covered in their formulary. It's a simple question and the answer is either Yes or No.

If NO, then an appeal to add the drug to the formulary starts with your physician - they have to contact your plan to start the process.

HTH.

 

[CRLLS]

I cannot help with the high tier meds.

DW is on Citalopram for an off-label use. It is made for Depression. DW uses is for a chronic cough. It only took her 20 years to find a resolution to her issue. Supposedly, it is also used for neuropathy. It has never been questioned by her WellCare Plan D. being a tier 1 drug, Her cost is zero for a 90 day supply. I could imagine where a higher tier drug might have some hoops to jump thru, possibly even be denied. I hope you find some answers that might help better than this.

 

[sengsational]

...

No need to call to find out if the drug is on the formulary...just download the list and search it. That's not the problem.

The link was meant to support the claim that "up to 1/3 of all prescriptions for common drugs in the US are off-label". The article is pointing out that there are problems with off-label use. I agree there are problems. One thing the article ignores are the barriers to doing a clinical trial; a phase 3 drug trial might cost over $100 million, and if it's a narrow audience for the drug, the business case doesn't hold up compared to other opportunities. But this wasn't the problem I was trying to get help with either.

And I agree that doctors are free to prescribe any legal substance (even one where the FDA is completely mute), it's the insurance companies that throw in the "FDA approved for a specific indication" rule. Drug X might be approved for indication "A", but not approved for indication "B". "B" would be "off-label" and so the insurance plan disallows it, but might allow it on appeal. That's what I'm asking about.

If I were already signed-up for a Medicare Part-D plan, and my doctor wanted to prescribe something specific off-label, sure, the staff at the doctor's office could try to get it approved. But that's not the case here. I'm not even 65 yet.

So the question is about specific experiences from members on this board for getting off label prescriptions through a Medicare Part-D plan. For instance, I can imagine where some plans make it harder than others to navigate the hoops to get an exception, and other plans make it easier. That's kind of what I'm going for. Which companies are a PITA and which are less so. Then I can work that into my decision when I'm selecting a plan.

 

[sengsational]

...

Thanks for the input on your experience with WellCare. As you say, it's probably easier on lower tier drugs. Maybe there's an unwritten rule that the FDA indication is ignored if it's not going to cost the insurance company much.

 

[sengsational]

Usually the SHIIP folks are called in for the initial Medicare decision. Has anyone contacted them to help with Parr-D appeals? If they sometimes help with drug appeals, they might know who's more accommodating in various situations.

 

[sengsational]

Usually the SHIIP folks are called in for the initial Medicare decision. Has anyone contacted them to help with Parr-D appeals? If they sometimes help with drug appeals, they might know who's more accommodating in various situations.

I just wrote a note to my state's SHIIP team. We'll see.

 

[GrayHare]

I began the exception process once, but stopped when I discovered the GoodRx price was less than my cost under the insurance plan, and 98% less than I would have otherwise paid.

 

[sengsational]

I began the exception process once, but stopped when I discovered the GoodRx price was less than my cost under the insurance plan, and 98% less than I would have otherwise paid.

Yeah. When I see that these Part-D plans' prices are significantly higher than what you can get through GoodRx, I figure not everyone is as effective at shopping as you are...they want to "use their insurance", and don't even know it's costing them more. A good pharmacy will check GoodRx without even being asked (mine does).

 

[CRLLS]

GoodRx vs Part D prices: if the difference is a buck or two, I go with the Part D provider. It is a small donation towards my Part D deductible. For anything $5 or more, I go with GoodRx or a similar discount service. Fortunately, Neither DW nor I have continuing medications, so the choice isn't necessarily that important at the moment, just the occasional meds required for some outpatient procedures.

 

[sengsational]

^ Yes, the "small potatoes" aspect of Rx, and medical visits, for that matter, really are a completely different topic than if you're talking "real money" associated with a high tier drug or hospitalization. A few doctor visits and even scans, if you get the insurance pricing, are smallish potatoes. Most Rx are small or smallish, with no chance of having high deductible insurance kick-in, and in those cases you might as well take the cheaper option and buy an extra bag of apples with the savings. But the decision to do one over the other is hardly worth much thought. Although I've got to believe that a lot of people always use their insurance, not even questioning if their price is the best or not. That makes Part-D providers clamor more for business, so, again, might as well take advantage of that fact by buying the cheapest Part-D plan out there if you don't have plans to use it. And you can always suffer through the months until you can re-select a better Part-D plan in annual enrollment.

 

[sengsational]

Just an update on my choice.

I discovered that the "star ratings" are by company, no plan. So if one company offers multiple plans, there's only one set of ratings. There is a separate rating for customer service, but those seemed irratic. I'm guessing that if one company offers several plans, all customer service calls will go through the same call center and escalation process, but that might not be a good assumption. Maybe the people who pay more (buy a more expensive plan) will get better service?

Then there's the plans that have a large fraction of "LIS" customers. Those are the ones that aren't paying for it themselves. I'm not sure my reluctance is justified, but I didn't know if being in a plan with people who did not pay their own way would tend toward more difficult relations with customer service.

Across all plans, I really could detect very little difference in coverage. There's certain requirements they all must meet, and any differences above and beyond that requirement seem small in comparison to the wide variation in price. I can get Wellcare for free, and some plans are over $100 per month. I don't get it.

I really might not even need to have the off-label drug, and I couldn't detect any provable difference between plans, I shopped by price. I'm skeptical of joining the zero cost plan (if something is too good to be true, there's got to be a catch), so I went with the Silverscript plan that's $5/mo.

This isn't a well-informed choice, but it uses all of the information I could find. Yet another case where it's impossible to be a good consumer of anything in the medical arena.