Accessing specialty medication remains a crucial aspect of patient care, particularly for those managing complex health conditions. Specialty pharmacies play a pivotal role in ensuring patients have seamless access to these vital medications. As the new year unfolds, it’s important to understand barriers to care and how we as a specialty infusion pharmacy can help.
Understanding the Role of Specialty Pharmacies
As an independent specialty infusion pharmacy, we provide injected and infused medications not typically found at your neighborhood pharmacy. These medications are costly, involve unique shipping/handling, and require patients to receive training or home nursing support to safely take the medication at home.
Because of the high level of care required to handle these complex infused or injected medications and the conditions they treat, we support our patients at every step. From prescription intake and insurance clearance, through medication delivery, training, and beyond, we are committed to our patient’s success.
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”.
How We Can Help
We employ staff who are very well versed in navigating insurance issues for specific health conditions. They use their knowledge to promptly obtain authorization for therapy and resolve coverage issues. We will 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.
What You Can Do
As a good first step in avoiding coverage issues, ask your provider to send a referral to BioMatrix or another reputable specialty pharmacy. If you have a new insurance plan, don’t wait until you are critically low on medication to place your first order. Placing your order in a timely manner will give your medical provider and specialty pharmacy enough time to resolve any issues before they potentially disrupt your care.
Step Therapy
Also known as a “fail-first” policy, step therapy requires you to try one or more preferred medications to treat a condition. You 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.
How We Can Help
If your health insurance plan involves step therapy, we can work with you and your prescriber to appeal the step therapy mandate and build a clinical case for maintaining the prescription as written by your provider. We will also make sure that there are no contraindications or anything else that would harm you with mandated prescribed medication. At BioMatrix, even if you must be prescribed an alternative treatment, our pharmacists make sure that it won’t be harmful or have adverse effects.
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, if you are enrolling in Medicare, you could reconsider Medicare Advantage and instead choose a Medicare fee-for-service plan to avoid being subjected to step therapy.
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.
How We Can Help
We can minimize your 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
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.
High Out-of-Pocket Costs
Living with a chronic condition is costly. When you have to pay high out-of-pocket (OOP) costs for your treatment, you're more likely to skip optional care and delay critical care. This leads to both poorer treatment outcomes and overall health.
How We Can Help
We are committed to helping you identify and obtain financial support so treatment can begin without delay. We help identify co-pay assistance programs and connect you with the right resources for enrollment. From manufacturer co-pay programs to charity-based financial assistance, we provide resources and support to reduce financial barriers and help you access specialized healthcare.
What You Can Do
We offer a Financial Resource Guide that you can download at no cost. It provides an understanding of the financial impact of chronic illness, a list of financial "safety nets" to put in place to help lessen the impact of healthcare costs, an overview of Medicare and Medicaid, tips to help avoid medical debt, and a list of financial support organizations who can potentially help. Click here to learn more.
Copay Accumulator Adjustors
A copay accumulator adjustor is an insurance-designed policy meant to control your 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 your 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 your responsibility. In 2023, the US Court of Appeals revoked the current language Health and Human Services (HHS) created in 2021 regarding copay accumulators. So be on the lookout for potential changes to come regarding the application or denial of manufacturer copay assistance toward your OOP responsibilities.
How We Can Help
We can help minimize the burden of copay accumulators by outlining your financial responsibility for prescribed therapy and referring you to appropriate financial assistance programs. Beyond manufacturer co-pay cards, there are many charity-based financial assistance programs that we can connect you with. These charity-based financial assistance programs can help cover both medical expenses and, in some cases, some living expenses.
What You Can Do
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. You can 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. 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.
You can also 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.
PBMs and Formulary Exclusions
A pharmacy benefit manager, or PBM for short, is a third-party partner with a health insurance plan that provides prescription drug benefits to the plan members. PBMs function as an intermediary between the entities involved in getting prescription drugs from the manufacturer to the patient’s individual insurance plans. If you have a health insurance plan, you have a PBM.
PBMs create drug formularies (a list of drugs that are covered by a health insurance plan) and therefore also formulary exclusions (a list of drugs that are not covered by a health insurance plan). If there is a formulary exclusion for your prescribed medication, you will have to pay for that out of pocket.
In 2023, formulary exclusions continued to increase with the top 3 PBMs (CVS, Express Scripts, and OptumRx). PBM exclusions tend to focus on drugs with low utilization, those with generic equivalents, or those used to treat chronic conditions. They block access to those drugs in favor of preferred ones. A patient-led study, however, claims that almost half (46%) of the exclusions in one PBM they studied showed no economic nor medical benefit for the patient.
How We Can Help
If your specialty medication falls under a formulary exclusion, we can work with you and your prescriber to appeal the exclusion and build a clinical case for why access to that particular prescription, as written by your provider, is required.
What You Can Do
If you want to learn more about PBMs, you can reach out to the BioMatrix Education Team at education@biomatrixsprx.com. You can also read more about them here.
The Road Ahead in the New Year
In the evolving landscape of healthcare, we continue to stay informed to help you overcome insurance plan barriers. We remain committed to advocating for our patients, staying updated on policy changes, and adapting our approaches to help ensure uninterrupted access to specialty medications. At BioMatrix, our employees also 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.
You can also 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 we are here to help you cut through the red tape of coverage issues.
DISCLAIMER: THIS IS NOT MEDICAL OR LEGAL ADVICE. All information, content, and material is for informational purposes only and is not intended to serve as a substitute for the consultation, diagnosis, and/or medical treatment of a qualified physician or healthcare provider or as legal advice. Please consult a physician or other health care professional for your specific health care and/or medical needs or concerns and never disregard professional medical advice or delay in seeking it because of something you have read here or on our website.
Financial Resource Guide
Living with a chronic condition can create additional healthcare costs while also impeding one’s ability to work. Our financial resource guide can help.
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