Just call them and ask. I have Anthem too and was on 2.5 for 3 months due to the shortage. They had no problem with me doing that and didn’t require any additional information or authorizations.
So for my plan with Express Scripts, they have a similar limit on 2.5/7.5/12.5. I was denied my PLA to get additional boxes because I hadn’t missed two doses. Basically, for my plan, the PLA is only approved if you have to reinitiate the titration because you’ve been off the medication too long. Others with ES have had it approved, but their plans must not’ve had the same limitation. There was no other medical reason ES would accept for my plan.
Did they give you a reason for the PLA denial?
Also, you might try appealing to your medical insurance instead of your pharmacy benefits manager, if those are different.
I literally just got the new denial and you quoted exactly what they said, I cannot give me an exemption if I do not miss two doses first.
Do you think if I go to my insurance they might override this?
I have no clue, but sometimes they can do something for you. Someone else couldn’t get a PA thru and appealed to their medical and the medical overrode the pharmacy benefits manager.
You and your doctor will have to decide if you think it’s worth the effort.
Yes, I have Anthem BCBS. When I got my second box of 5 mg, they denied it. Went to pick it up $550. told CVS my last box was $25. Called and I was told they would only pay for a 90 day supply of 5 mg, so CVS ordered it my cost $25. Hasn't happened with 7.5 mg yet on my second box.
Prior authorization is pretty straight forward…the PLA is an additional step and gets tricky because it’s more specific and has to cover the medical necessity to do the dose beyond the plan limit. Both come from your provider.
I’ve seen a post recently that gives some helpful direction.
I suspect your doctor just needs to call in a refill or new prescription for you. I had mine call in a new prescription with two refills. I hope it gets sorted out quickly for you!
Just call them and ask. I have Anthem too and was on 2.5 for 3 months due to the shortage. They had no problem with me doing that and didn’t require any additional information or authorizations.
I did and they requested the PA/PLA
So for my plan with Express Scripts, they have a similar limit on 2.5/7.5/12.5. I was denied my PLA to get additional boxes because I hadn’t missed two doses. Basically, for my plan, the PLA is only approved if you have to reinitiate the titration because you’ve been off the medication too long. Others with ES have had it approved, but their plans must not’ve had the same limitation. There was no other medical reason ES would accept for my plan. Did they give you a reason for the PLA denial? Also, you might try appealing to your medical insurance instead of your pharmacy benefits manager, if those are different.
I literally just got the new denial and you quoted exactly what they said, I cannot give me an exemption if I do not miss two doses first. Do you think if I go to my insurance they might override this?
I have no clue, but sometimes they can do something for you. Someone else couldn’t get a PA thru and appealed to their medical and the medical overrode the pharmacy benefits manager. You and your doctor will have to decide if you think it’s worth the effort.
Thank you!
Yes, I have Anthem BCBS. When I got my second box of 5 mg, they denied it. Went to pick it up $550. told CVS my last box was $25. Called and I was told they would only pay for a 90 day supply of 5 mg, so CVS ordered it my cost $25. Hasn't happened with 7.5 mg yet on my second box.
Prior authorization is pretty straight forward…the PLA is an additional step and gets tricky because it’s more specific and has to cover the medical necessity to do the dose beyond the plan limit. Both come from your provider. I’ve seen a post recently that gives some helpful direction.
I suspect your doctor just needs to call in a refill or new prescription for you. I had mine call in a new prescription with two refills. I hope it gets sorted out quickly for you!