Legal News
Psychiatrist Battles Part D Plan
Psychiatric News
Volume 41 Number 15 page 13-13

Following is an excerpt from a letter to an administrative law judge by psychiatrist Elizabeth Delasante, M.D., describing her efforts to get coverage approval for a Geodon prescription for a patient in Medicare Part D (see article at left):

"On January 8, 2006, [the patient] went to the local Wal-Mart pharmacy to refill her prescription for Geodon. The pharmacist informed her that prior authorization was needed and that I, the prescribing physician, should call Medco to obtain it. I called Medco on January 9, 2006, and was told that prior authorization was not necessary and to tell the pharmacy to `override it.' I instructed [the patient] to return to the pharmacy, but the pharmacy would still not refill the prescription for Geodon, again stating that prior authorization was necessary.

"On January 11, 2006, I requested a coverage determination from Medco. In response, Medco sent me a fax, which had the following box checked: `No coverage review available.' I appealed this coverage determination that very day. I did not receive a timely response to this appeal, so on January 16, 2006, I called Medco to ask about the status of the appeal. I was told that they had accidentally thrown away the appeal, but had documented receiving the appeal in the records. They asked me to resend the appeal, which I did.

"On January 20, 2006, Medco sent me a letter stating that because no decision had been rendered within 72 hours, [the patient's] appeal had been automatically forwarded to an independent review organization, and a decision would be made by Maximus, in King of Prussia, Pa.

"On January 26, 2006, Maximus sent me a letter stating that the appeal decision was unfavorable, with the explanation: `Our decision is that Medco Health is not required to provide coverage for Geodon because we were unable to find documented evidence to support the use of the drug Geodon at the daily dose of 320 mg (160mg twice daily).' On February 1, 2006, I responded to Maximus requesting that the case be reopened because I had articles and abstracts that supported the dose of Geodon that [the patient] was taking. On February 9, 2006, Maximus sent me a letter rejecting my request to reopen the case."

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