Question
I am legally disabled with genetic (degenerative) inflammatory disease(s)...After a decade of successful yearly prior authorizations for 'the ONLY' medication that allows me to achieve any quality of life, I was recently denied the latest prior approval. My current provider/prescribing physician has been my doctor for 1 year, as my previous doctor retired this time last year. I was told by a Medicaid prior authorization manager that the prior authorization request form had been changed within the last year in an effort to make patients use generic, lower cost medications and had my doctor answered 'yes' on the question: 'if I had been prescribed a generic/similar medication and documented it unsuccessful', then the prior authorization would have been approved. There is 'NO generic' available for the medication (as it was pulled from the market) and I HAVE TRIED other 'similar medications in years past without success. I desperately need this particular medication in order to function in any productive manner and have filed for an appeal. Any advice you can offer regarding winning my appeal would be greatly appreciated, as I will certainly be hospitalized without it due to my condition and the degenerative nature of my disease. Thank you & Kindest Regards...T~
Answer
Hi Tod
That is a tough appeal.
See if the doctor will file a new form.
Try and document the removal of the Generic.
But most important is a strong letter from the doctor that your specific drug is the only known on that can help your condition and there is no known generic.
Lots of luck
John.
