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I think you meant to say if a drug is NOT listed? Even then , Tier 4 & 5 drug approvals are a "crap shoot" for us, depending on who is the Pharmacy Benefit Manager (PMB). This year we were fortunately able to switch away from the plan that gave us endless grief last year, even on some Tier 3 medications. Last year I spent over 150 hours on prior approvals, appeals, and more for Tier 3 & 4 medications, this year maybe 20 hours?
Another thing about formularies - the listing is not the "whole story" each medication may also have codes which indicate limits on dispensing, whether "step up" therapy is required (trying other cheaper meds first), and whether prior approval is required.
@irenea8 If I was starting this process, I would look for an independent (not tied to one insurance provider) Medicare consultant to walk me through this.
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Over 150 hours on prior approvals etc. etc. Wow. Glad it went down to 20 hours in 2025. Interesting what Rick said. I do believe it is typical that NJH has a history of being able to secure medical needs for their patients. They were able to secure the Hill Rom vest for me immediately....however....for me it was not doing the 'trick' so it got sent back by me. Just hope that all who had a right to receive a credit got the credit from Hill Rom as they said would happen.
My thoughts: I wouldn't be a bit surprised if we see a company eventually who will go to battle for patients in their fight with the Pharmacy Benefit Managers to get meds approved for patients. Of course at a cost to the patient but in some cases it might be worth it for some depending upon total cost and for a life saving medication.
So much to know regarding insurance requirements and coverages.
Thank goodness Sue you had the energy, time and ability to fight the fight.
Barbara