As a lead case manager for Cystic Fibrosis Foundation Compass, I often get calls from people with cystic fibrosis and their families saying, “My pharmacy told me that my medication isn't covered.” It makes you anxious, it makes you worried and it makes you wonder how you are going to pay for the medication that you absolutely need. Rightly so! With a chronic condition such as CF, we all know how important it is to have timely access to prescription CF treatments and therapies.
Don't panic! There are steps you can take to help you understand insurance coverage.
The first thing to do is to call your insurance company and find out why the medication is not covered. Here are a few key questions you should ask:
1. Is there any coverage restriction on the prescribed medication?
Often a health plan requires a prior authorization both to ensure that certain medications are being prescribed for an appropriate use, and as a cost-saving measure. Although your doctor may simply call in the prior authorization over the phone, some health plans require the doctor to submit a prior authorization form. This process can take up to 72 hours for standard requests. Ask your doctor if he or she can submit an urgent request, which will be reviewed by the health plan within 24 hours. Keep in mind that even if the medication is approved, the approval may be valid for only a limited time, so it is important to plan your refills accordingly, giving that extra time for obtaining a prior authorization. You may be able to ask your pharmacist if your health plan will allow for an emergency fill, usually 10-15 days of supply, while you wait for your medication to be approved.
Another thing to consider is that your plan may impose quantity restrictions, which means that it will only cover certain amounts of a prescription. If your doctor is prescribing at doses higher than normal, the prescription may be denied. You will find that the quantity limits are common with pancreatic enzymes, as people with CF are often prescribed higher doses to maintain adequate weight and growth. Finally, your plan may also require a step therapy. This means that your doctor must clinically show that you have tried and failed taking a less expensive or preferred medication on the formulary before your plan will cover the prescribed medication.
If your plan is denying your medication because of coverage restrictions, first work with your doctor to see if an unrestricted covered medication will work for you. If it is medically necessary for you to take the prescribed medication, your doctor will need to make a formal request to override the coverage restriction by submitting a supporting statement to your insurance provider that the standard dosage or medication has been or is likely to be less effective than the one being prescribed.
2. Is the medication on the formulary?
A formulary is your health plan's list of covered medications. If your medication is not on the plan formulary, your doctor may ask for a formulary exception to cover the medication that is medically necessary for you. Your health plan may have a form for requesting a non-formulary medication or may require your doctor to submit a supporting statement that the non-formulary medication is necessary for treating your medical condition.
3. Are there alternatives that the plan will cover?
Your plan may only cover the generic and not the brand-name medication, as generic medications usually cost less. Don't be afraid to ask your doctor if the generic may be substituted for a brand medication. However, this may not be an option for some CF medications, such as pancreatic enzymes, for which a specific brand is medically necessary.
4. Can it be covered under the medical portion of your plan benefits?
Quite a few people with CF and their families have called us with concerns about compounded medications not being covered under their plan's pharmacy benefits. Although insurance coverage for off-label use may vary from plan to plan, we have found that these compounded medications may be submitted for coverage under the plan's medical benefits.
So, we talked about some limitations imposed by your health plan that may delay insurance coverage for your prescribed therapies. If you are like many people with CF and their families who dislike trying to find insurance coverage, CF Foundation Compass case managers can take the burden off you. So talk to us about your specific situation and let us help you navigate through some of these coverage issues. You can reach us by calling Compass at 844-COMPASS (844-266-7277) or emailing us at firstname.lastname@example.org. We are here for you!