Medicare Answers: High-Cost Drug Not on Formulary

  • Originally published December 1, 2015 , last updated December 29, 2015
Medicare Answers: High-Cost Drug Not on Formulary

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Q. I have a client currently on a PDP. She's taking a lung cancer drug called Tarceva, which is Tier 5 and very expensive. She will definitely hit the catastrophic coverage. It's more effective than her other meds but is not defeating the cancer.

Earlier this month the FDA approved a new drug from AstraZeneca called Tagrisso — but it's something like $13,000 per month. The doctor will prescribe it for her, and we're trying to get it covered, but since it's new it's not on ANYONE's formulary for 2015 or 2016. My normal carriers are basically saying there won't be any formulary changes and the only thing we can do is the appeals process to try to get it covered, which we will do of course. Are there any other options?

A. In addition to the appeals process, call the manufacturer of the drug and appeal on financial need. Most pharmaceutical manufacturers have programs for those on low income, above the normal Low-Income Subsidy levels. We have seen some notable exceptions, such as the price of a drug dropping from $7,200 to $720.