The New Year can be an exciting time—a time to reset goals and commit to forming new habits. But for those with chronic conditions, the New Year can also bring some unforeseen challenges and barriers to healthcare. In addition to resetting personal goals and habits, health insurance plans and deductibles reset too. In this article, we’re going to review common coverage terms and barriers to care, what you can do to potentially overcome some of these barriers, and how specialty pharmacies can help.
Prior Authorizations
Prior authorizations are a cost-control process that requires advance approval for certain healthcare needs, especially specialty medications. This process can take 5-10 days (though typically fewer with BioMatrix), needs to be reviewed by clinical pharmacists and medical doctors, and may require a letter of “medical necessity”.
What You Can Do
Don’t wait until you are critically low on medication to place your first order with your new health plan. Placing your order in a timely manner will give your medical provider and specialty pharmacy enough time to resolve any issues before it potentially disrupts your care.
How Specialty Pharmacies Can Help
Specialty pharmacies, like BioMatrix, can work together with your medical provider and health plan to obtain timely prior authorization for service and assist when and if an appeal is necessary.
Asking your provider to send a referral to BioMatrix or another reputable specialty pharmacy is a good first step in avoiding coverage issues.
Step Therapy
Also known as a “fail-first” policy, step therapy requires the patient to try one or more preferred medications to treat a condition. The patient must first “fail” medication before “stepping up” to another drug. The issues with step therapy may include potential side-effects, insurer vs physician control over patient care, and delay of therapy if the patient appeals. The implementation of step therapy has been steadily increasing.
What You Can Do
When it comes time for open enrollment, check whether you have any available plan options that don’t include step therapy. For example, in an interview with Specialty Pharmacy Times, Community Oncology Alliance Executive Director Ted Okon, MBA, advises that “...patients reconsider Medicare Advantage and instead choose a Medicare fee-for-service plan to avoid being subjected to step therapy.”1
How Specialty Pharmacies Can Help
In the same interview as mentioned above, if a patient’s plan does include step therapy, Okon advises pharmacists to “...make sure that there are no contraindications or anything else that would harm the patient. The pharmacist is on the front line in getting the right drug to the patient.”1 At BioMatrix, even if the patient must be prescribed an alternative treatment, our pharmacists make sure that it won’t be harmful or have adverse effects for the patient.
Denied Claims and Appeals
In the event of a health insurance claim denial, an insurer refuses to pay for a procedure, test, or prescription. This could be due to a number of reasons including an error in how the claim was entered or due to missing information.
What You Can Do
When an insurance claim is denied, you have the right to appeal. To proactively make the appeal process easier, keep detailed records, and document every call you have with your insurer. Take notes on the following:
- Date/time of call
- Reason for call
- Name of the employee(s) you spoke with
- Reference number for call (you may need to specifically request a reference number)
- Result of the call and any impact on your health resulting from the issue/call
Check with your insurance provider to determine their specific appeal process. Don’t hesitate to involve your medical provider and specialty pharmacy for additional assistance.
Investigate the explanation of benefits and use (EOB) to understand any claims and/or denials of coverage. If there is a denial, use the denial of coverage code found on the EOB or denial letter in all correspondence.
How Specialty Pharmacies Can Help
Specialty pharmacies can minimize denied claims and provide support for appeals by:
- Conducting a thorough benefits investigation on your behalf
- Providing a detailed outline of coverage specific to your therapy, including whether it is covered under the medical or pharmacy benefit and if a prior authorization is required
- Outlining financial responsibility for prescribed therapy and referring to appropriate financial assistance programs
- Identifying specialty pharmacy service providers available under your plan
- Providing support for timely prior-authorization and appeals
High Out-of-Pocket Costs
Chronic conditions are costly. When patients are forced to pay high out-of-pocket costs, they are more inclined to skip optional treatment and delay critical care.2 This leads to both poorer treatment outcomes and overall health.
How Specialty Pharmacies Can Help
Research shows specialty pharmacies drive down the cost of care in a variety of ways by promoting adherence to therapy, identifying utilization or dosing mistakes, helping to avoid unnecessary hospitalizations, and connecting patients with financial support programs.3
Out-of-pocket (OOP) costs are covered for 93% of BioMatrix patients by either manufacturer copay or 501c3 foundation support, and 44% of BioMatrix patients have achieved $0 OOP associated with their prescribed therapy.
Copay Accumulator Adjustors
A copay accumulator adjustor is an insurance-designed policy meant to control a patient’s cost sharing agreement with the insurer. The insurer will accept the drug manufacturer copay cards towards prescribed drugs but will not apply that amount toward a patient’s OOP. The pharmacy will be required to collect these cost shares again and can use the drug copay card until the card is at $0. Then the OOP cost will be the patient’s responsibility.
What You Can Do
Find out if you have a copay accumulator by calling your plan. Recent CMS rulings require that insurers provide “clear and transparent” information to consumers about copay accumulator policies.4 It also goes by different names depending on the plan:
- Copay Maximizer
- Coupon Adjustment Program
- Benefit Plan Protection Program
- Out of Pocket Protection Program
If you have to choose between a plan with a copay adjustor and a copay maximizer, a copay maximizer, while still not ideal, is potentially better. With a copay maximizer, the insurer will accept the drug manufacturer copay card towards a prescribed drug and will apply that amount toward a patient’s OOP for that drug only. So, while the OOP for that particular drug doesn’t apply to other healthcare costs, at least it will apply to that drug which may account for a high percentage of your healthcare expenditure.
Another thing you can do is choose a health savings account (HAS) or flexible savings account (FSA) plan where you can put pre-taxed money away for your deductibles and OOP costs.
While an increasing number of plans now have copay adjustors, making a personal decision about your plan choice based on an accumulator adjuster is an example of private, personal advocacy, and is of vital importance to your continued access to affordable healthcare. You may be locked into your current plan if open enrollment has passed, but keep this in mind for the next open enrollment period. This article gives more information on how you can become an advocate regarding copay accumulators at a state and national level.
How Specialty Pharmacies Can Help
Specialty pharmacies can help minimize the burden of copay accumulators by outlining financial responsibility for prescribed therapy and referring to appropriate financial assistance programs. Beyond manufacturer co-pay programs, there are many charity-based financial assistance programs that specialty pharmacies like BioMatrix can connect you with. These charity-based financial assistance programs can help cover both medical expenses and, in some cases, some living expenses.
In summary, you can be your own advocate when it comes to health insurance coverage. Be proactive when ordering medication, stay organized, and be aware of what your policy entails. Also remember that specialty pharmacies can help you cut through the red tape of coverage issues.
At BioMatrix, our employees have a great deal of experience with specific health conditions. By utilizing this experience and knowledge, we can obtain authorization for therapy and resolve coverage issues promptly. We ensure patients understand their specialty medication insurance coverage, conduct comprehensive benefit investigations, help with prior authorizations and appeals, and coordinate care to help patients quickly begin therapy and maintain access to their specialty medication.
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References
S. Fyfe. (2019). What Pharmacists Should Know About the Pitfalls of Step Therapy. Pharmacy Times. https://www.pharmacytimes.com/view/what-pharmacists-should-know-about-the-pitfalls-of-step-therapy
Stacie B. Dusetzina , Aaron N. Winn, Gregory A. Abel , Haiden A. Huskamp , Nancy L. Keating. (2013). Cost sharing and adherence to tyrosine kinase inhibitors for patients with chronic myeloid leukemia.Journal of Clinical Oncology. 32, no. 4 (February 01, 2014) 306-311. DOI: 10.1200/JCO.2013.52.9123
Joo EH, Rha SY, Ahn JB, Kang HY. Economic and patient-reported outcomes of outpatient home- based versus inpatient hospital-based chemotherapy for patients with colorectal cancer. Support Care Cancer. 2010;19(7):971-978. doi:10.1007/s00520-010-0917-7
CMS. “Patient Protections and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for 2021.” https://s3.amazonaws.com/public-inspection.federalregister.gov/2020-10045.pdf
