Recently had a patient switch to Health Net. They had been getting their medication for years without problem, but now Health Net says otherwise.
They sent their Prior Authorization / Formulary Exception Request Fax Form to us to complete, which we did. We included everything requested on the form and the last chart note.
We received their answer back in less than a day: DENIED. Why? According to their denial letter, they require the patient to have “Failure of two of the following unless contraindicated or clinically significant adverse effects are experienced: transdermal fentanyl patches, extended release oxymorphone.
The problem with that is extended release oxymorphone is NOT available for prescriptions anymore. It was taken off the market by the manufacturer at the request of the FDA in 2018.
So if there are only two drugs to try and fail, and one of them is not obtainable, then everyone gets DENIED automatically.
They also requested multiple elements of a “treatment plan” yet never listed any of them on their request form!
I sent back their denial letter with the above noted on it and their response back? They sent back the exact same letter that I sent them with no added information or response. They just ignored what I pointed out to them.
Are they idiots or just ignorant? Are they just going through the motions of the denial process?
They clearly added this sentence to their response to “justify” their actions: Your doctor has not provided us with the required information listed above.