Posted by zonked on September 22, 2011, at 20:16:24
Scott,
I am feeling pretty good and energetic today, so I thought I'd use that opportunity to consolidate what I know, and how you might be able to get Viibryd. None of this may be of use to you but were I in your situation I would do this.
1. First, call your doctor and have him contact Forest immediately to get samples to cover you through the end of the year, if necessary.
2. I found many drug plans that cover Viibryd on Medicare.gov - if you have Medicaid or receive SSI, you can switch plans at any time without penalty. When you use the Plan Finder tool, on Medicare.gov be sure to personalize it using your Medicare claim number, effective dates for Part A and B and birthdate so it can show you your estimated drug costs with any LIS ("extra help") included in the calculations. Also include any drugs you take now or plan to take. It is so much easier than browsing individual formularies.
3. I am assuming you have standard Parts A and B, a part D plan (PDP), and Medicaid. Some of this won't apply if you have a part C plan (Medicare Advantage) instead; but the plan finder tool will show MA plans that cover Viibryd as well.
4. I am also assuming that you have Medicaid as well. If you have asked that the part D plan allow a formulary exception (which is your right under federal law) and they have denied it, you can then ask the Pharmacist to bill Medicaid. If they deny it (they probably will) you can ask your doctor's office to file a TAR/Prior Auth request for Medicaid, since at this point you will have exhausted all your Medicare options, and may be what you need to do to secure a supply while you switch plans.
5. Once Medicaid denies it, and I am basing this on California Medicaid policy, you can request a State Fair Hearing with an administrative law judge to have ask that it be covered. I have been advised that should I ever run into this siutation, the administrative law judges usually do what the doctor wants as long as the drug in question is being used "on label" which in this case it is.
I hope you don't have to go through all of this to get Viibryd. I think you *really* should ask your doctor to call Forest immediately to get you sample coverage while you ponder the above. Your best bet is to simply get samples from him and choose a Medicare Part D or MA (part C) plan that covers Viibryd, and use the samples until October or November 1, or January 1 if you can't change Part D/MA plans without penalty.
I have made assumptions about your coverage. If you don't get Medicaid OR if you don't get any SSI, you can't switch Medicare Part D or MA plans without penalty. Also, Medicaid works differently in each state.
Best to you man, you deserve some relief,
-z
poster:zonked
thread:997564
URL: http://www.dr-bob.org/babble/20110914/msgs/997564.html