The clinicals were fine. The formulary was the problem.
Key Takeaways
- Branded drugs often sit behind step therapy. This patient’s plan wanted a preferred alternative tried first.
- Checking the formulary before submitting is the single most useful step for any branded prescription.
- Two clean paths forward exist, and the prescriber chooses.
The case
An Aetna Medicare HMO member was diagnosed with dry eye disease. Her ophthalmologist prescribed Xiidra, and the office started a prior authorization request.
She had not tried any other prescription dry eye drops, and no one checked the plan’s formulary before preparing the request.
Why this request was at risk
Xiidra is a branded drug, and plans commonly place it behind step therapy. Under step therapy, the patient must first try the plan’s preferred alternative, or the prescriber must document why that alternative is not appropriate.
Sources: Cigna Drug Coverage Policy IP0644: Xiidra; Express Scripts Xiidra Prior Authorization Policy
This patient’s plan listed Miebo as the preferred alternative, and she had not tried it. A request without either the trial or a clinical justification would be denied on step therapy, no matter how well the dry eye disease was documented. Skipped steps are one of the most common daily denial triggers our team sees.
What our team checked
- Is Xiidra on this plan’s formulary, and is it subject to step therapy?
- Which preferred alternatives does the plan require first?
- Has the patient tried any of them, or is there a documented reason she cannot?
What we did
Our specialist checked the plan’s current formulary before anything was submitted and brought the step therapy requirement to the practice with two options:
- Prescribe the preferred alternative first, or
- Document the clinical reason the preferred alternative is not appropriate, such as a contraindication or a prior failure, and submit the request with that justification.
The prescriber decides which path to take. Either one produces a request the plan can act on. Submitting with neither produces a denial.
The documents that close the gap
What our team sees most often
Xiidra requests submitted before the plan’s preferred alternative was tried. On this patient’s plan, that alternative was Miebo.
A question for your team
Does anyone on your team open the formulary before the PA form?
Want a prior authorization team that reads the chart and the plan before every submission? Talk with DataMatrix Medical.
More from this series: see all six prior authorization case studies.
This case is drawn from a real prior authorization request our team handled. We removed identifying details to protect patient privacy. Payer policies change and vary by plan, so the same steps will not produce the same result in every case. This article is educational and is not legal, billing, or clinical advice.
Nathaniel Smathers is the VP of Client Education and Marketing. He is also a long time contributor of the DataMatrix Medical blog and has a background in healthcare content creation for over a decade. Nathaniel is passionate about exploring the intersections of healthcare, data analysis, and digital innovation.
