In order to manage growing drug plan costs, private payers are implementing several plan designs to manage specialty drug use:
- Special or prior authorization: a patient or their physician must submit additional information for the insurance carrier to review to ensure the patient meets specific criteria before coverage is confirmed. The review could include clinical information, prior treatments and/or diagnosis.
- Case management: like special or prior authorization but requires much more information to be provided to the insurance company’s case manager who will review the treatment plan and consult with the physician. Case managers may recommend an alternate treatment or monitor the patient to ensure that they obtain the best possible outcomes.
- Preferred pharmacies: Some private plans require patients to use a pharmacy or chain exclusively, and others offer a more reimbursement for patients who use these pharmacies. Some insurers have partnered with specialty pharmacies for exclusive distribution of biologic treatments to patients.
- Managed formularies: Their drug plans pay only for a selection of effective and affordable drugs. Their insurance carrier or pharmacy benefit manager will manage the formulary on behalf the employer.
If you have been denied coverage or the co-pay is unaffordable, here are some options we recommend:
1. Write to your Human Resources Manager and request an employer exception
When the insurance carrier says a drug is not covered, it is usually because the specific insurance plan chosen by the employer does not cover the drug. The insurance carrier is following the terms of the insurance contract chosen by the employer. Because the employer chose the plan, they may have the opportunity to ask the insurer to pay for a drug that is not covered by the drug plan. This is called an “exception” or “extra-contractual coverage”
Any exceptions must be agreed upon by both the insurer and the plan sponsor and this may affect the price of the whole insurance plan. To accommodate a special request, the employer and insurer will look at the financials of the drug plan to see if additional premiums are needed to accommodate a claim for a drug that was not included in the initial plan and premium calculation.
This avenue of exceptions depends a lot on the size of the employer and the financial arrangements with the insurance company. Large employers may have more flexibility to negotiate an exception with their insurance carriers, although they may not have the budget or wish to set a precedent. In the end, each request is case-by-case basis and reviewed against the terms of the specific contract in place.
- Know the warnings and contraindications of your treatment to the prerequisite medications that need to be considered, in conjunction with your physician. Together best navigate the stepped approach for your optimal treatment.
- Other options such as Patient Support Programs and Clinical Trials (see Other Access Options section