ISSUE: Sometimes a switch from one medication to another can introduce difficulties in the approval and coverage process. This was the case for a Veteran suffering from an autoimmune disorder, whose doctor prescribed a different medication after the previously approved treatment caused uncomfortable and unmanageable side effects. Although the specialist provided a thorough rationale, because the medication in question was not included in VAC's standard formulary, or list of approved medications, coverage was denied. The necessary medication cost thousands of dollars per month and the Veteran faced the choice of either continuing to suffer, or paying out of pocket in order to treat his disability entitled condition. He contacted the OVO and asked us to intervene.
Time was of the essence for this Veteran, and while the VAC process would usually direct the Veteran to appeal the decision and await the results of that review over the course of up to three months, the file took a shorter route thanks to OVO assessment and intervention.
ACTION: VAC’s Exceptional Benefits Unit examined the evidence along with the specialist’s detailed explanation of why other potential medication options were inappropriate or even harmful to the Veteran’s health and well-being. Within a week, VAC approved coverage of the prescribed medication.
RESULT: The Veteran received retroactive approval and was able to access the expensive medication all within a few weeks of contacting our office.