Share your Stories of Delays/Disruptions in Your Patient's Eye Care Treatment

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* 1. Contact Information

Your Name

Your Home State

Your ZIP Code

Your Email Address

Your Phone Number

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* 2. What eye health problem(s) are you treating?

Glaucoma

Diabetic Retinopathy

Age-related Macular Degeneration (AMD)

Vascular Occlusion (CRVO/BRVO)

Other (please specify)

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* 3. Do you feel that your patient or practice was informed/aware of all the treatment options for your patient's condition?

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* 4. Was a patient denied coverage for a treatment or medication you prescribed?

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* 5. If yes, what is the name of the treatment or medication?

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* 6. Did this case involve a prior authorization denial or step therapy denial?

Prior Authorization Denial - requires plan approval for coverage of a prescription

Step Therapy Denial - requires the patient to try a drug, like an off-brand or cheaper drug regardless of clinical effectiveness, before trying a costlier or brand-name drug

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* 7. Was your patient required by their plan to try a different drug before obtaining the drug you prescribed for his or her treatment?

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* 8. What was the impact to your patient’s health and/or vision condition as a result of your patient’s plan’s requirement to try a different drug than what you had prescribed

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* 9. Did your patient appeal the plan's decision?

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* 10. If the patient did appeal, was the appeal successful?

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* 11. If you recall, please provide the name of the patient’s health plan

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* 12. Please provide any other comments you may have about the case.

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* 13. May we contact you to find out more about your and your patient’s story, or to obtain your patient’s permission to share his or her story?

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* 14. What is your preferred method of contact?

phone

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* 15. Would you like to get involved and speak up about the issues you have experienced with Step Therapy?

Please Note:

Prevent Blindness may reach out to you about telling your treatment story to members of a state assembly, becoming a volunteer spokesperson for the initiative, to obtain express patient permission to share a story, or for other opportunities to share your story to the public.

The information you have provided in this form will NOT be shared with any private entity including corporations or businesses, employers, or insurance companies. By volunteering to share your treatment story, you will help us educate policy makers about the potential impact of Step Therapy on the eye health patient. Thank you for sharing!

Please contact Sara Brown, Director of Government Affairs, with any questions:
sbrown@preventblindness.org
312.363.603