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Prescription Medication: A Case Study

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A review of the records reveals the member to be an adult female with a birth date of 03/14/1983. The member has a diagnosis of Generalized Anxiety Disorder. The member’s treating provider, Vickki-Ann Samuel, MD recommended the member continue treatment using the prescription medication Pexeva 30 mg. The carrier has denied continued coverage using the prescription medication Pexeva 30 mg as not medically necessary. There is a letter from the carrier to the member dated 04/15/2016 which states in part: “The specific reason for this denial of your appeal for benefits is that Pexeva is not listed on AvMed’s Commercial Medication Formulary; therefore it is not a covered medication. The documentation submitted does not show the specific details that you have an adequate trial and failure of or have contraindication to ALL formulary therapeutic alternatives, including Paroxetine IR and Paroxetine ER. Requests for a non-formulary product require a letter of medical necessity AND a description of contraindications to or therapeutic failures of an adequate trial of each AND all formulary alternatives.” There is a letter from Vickki-Ann Samuel, MD dated 04/14/2016, that states in part: “Dawn Bichachi has been taking Prexeva for over three years. Her symptoms are stable on this medication and dosage, 30mg. Prior to becoming stabilized on …show more content…

Specifically, the coverage guidelines state that Pexeva, a non-formulary medication utilized to treat anxiety, cannot be granted due to information not being provided in the form of a letter of medical necessity and documentation indicating that the physician has tried and failed all formulary alternatives, including

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