Marybeth Ellison, MD, FAAP

Updates to Visit Policy 12/2023

 

We are certainly living in unprecedented times, and we need to be vigilant while continuing to provide medical care for our patients. On that front, we have implemented policies that mirror the ones that our teams are using at Yale. Due to the COVID – 19 pandemic and the recommendations of the CDC and the American College of Physicians, actions have been implemented to effect social distancing and allow us to care for patients in as safe a manner as possible.

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Patient Appointments​

• Visits for Patients on Medications or with ongoing challenges:  Patients who have clinical reasons to be seen will be asked to come in for their visit as long as they are well and screen “Coronavirus Negative”. This means: NO recent fever, NO active cough or significant respiratory symptoms, and NO known exposure to someone who is positive for COVID-19.

• In keeping with the updated policies at Yale New Haven Hospital 12/2023, you and your child are expected to wear a mask if any viral symptoms are present.

• Tele-health visits:  Patients who have a scheduled appointment but have had recent illness or exposures, and are having issues that require a medical or behavioral health follow-up visit, should arrange this type of visit by calling ahead. Most insurance companies are allowing these visits given the current circumstances.

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Thank you for your understanding as we try to provide essential medical services in the safest way possible. If you have questions, do not hesitate to call our office or email us at sunflowerdevelopmentalpeds@gmail.com.

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Additional Information Regarding Medication Shortages

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Many medications that are commonly used to treat ADHD are currently in short supply nationally. Mail order pharmacies seem to be able to get them more easily, and it prevents you from having to search again 30 days later, as they provide 90 day prescriptions. Some smaller local independent pharmacies are also willing to work harder and can obtain these medications more easily at times. Before you set out to refill your child’s medication, CALL your usual pharmacy. If they do not have –or anticipate getting—your child’s medication in, we suggest you call various pharmacies to try to locate the same medication and dose if it is working well. If your child’s medication is not available, we can submit a replacement medication of a similar class, see attached list. Some formulations will be different, and we have no way of knowing that until we try it unfortunately. The active ingredients are the same or extremely close compounds.

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Adding to the challenge, insurance carriers can be very frustrating to work with and at times may cover some medications but not all. They often have financial relationships with pharmaceutical companies which dictate what their preferred medications are. Most insurance companies want patients to use generic medication, and in many cases, there are biological equivalents which work quite well i.e., Focalin XR and Dexmethylphenidate ER. All of the stimulant medications (methylphenidates and amphetamine based) may have similar active ingredients but different profiles on how they are released in your body.

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Frustratingly, even with medication shortages, the insurance companies are resistant to using medications if they are not on formulary; even if they are on their formulary, they are often Tier 3. Our office can complete a Prior Authorization (PA), but this can be complicated based on your insurance.

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Process of a PA include several steps, but the initial step for the PA is initiated by the pharmacist. They submit this information to a third-party program to start the PA, usually CoverMyMeds which is an online platform. If the pharmacist does not do this, it is not given a case number, and I have no way of accessing the insurance data needed. Once that is sent by the pharmacist to CoverMyMeds, that platform sends a notice to our office email. I them go on to that secure website and submit the PA; there are usually 3 steps: 1- confirm that the patient has the insurance (quick), 2-submit the diagnosis codes, medication request, reason for choosing that medication etc. At this stage, it is sent to them for review, and I cannot attach notes or other data; this takes 3 to 5 business days usually. We then get notified by email a decision has been made and to log on to the platform.  It may be:  A-approved (rare), B-need more information (at which points I submit office notes) or C- denied because you have not failed the needed number of prerequisite trials of generic medications. If it is ‘B’ I do this within 3 days, they then have another 3 to 5 days to review and consider to make a final determination.

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If it is denied, we can discuss other similar medication options, or you can pay out of pocket. Calling you insurance representative may result in a second review and consideration, but often it does not. For several of these medications, the drug manufacturer or distributor offers ‘coupons’ or programs that when filled at certain pharmacies make them more affordable. If that is the case, our staff will share that information and try to assist you.