Dear Addy: Coverage for New Therapies

Dear Addy,
I want to switch to a new hemophilia therapy and, though my doctor has prescribed the product, my insurer won’t authorize coverage. How can I get this covered?
Signed,
Concerned Consumer

Dear Consumer,
When new therapies come on the market, there is often a lag before health plans add those products to their formularies (the lists of preferred medications that the health plan will cover). Unfortunately, we are now seeing formulary restrictions with respect to new treatments for bleeding disorders. It will take some legwork by you and your doctor – and success, unfortunately, is not guaranteed – but there are some steps you can take to try to gain access to a therapy that is not on your plan’s formulary.
First, you should work closely with your doctor to ask for a formulary exception from your health plan. Your doctor should submit documentation making the case that there is “clinical necessity” for you to use the new product. As part of this process, you may have to undergo and submit additional medical testing, e.g., half-life studies. In general, your health plan will be required to respond to your request within 72 hours.
If your health plan denies an exception, you may opt to pursue an internal appeal of that denial. The internal appeal process will require you to complete any forms required by your health insurer (these may or may not be online), and submit any additional information that you want the health insurer to consider, such as a letter from your doctor. Make sure you keep copies of all your information related to your claim and the denial.
If you do not prevail on your internal appeal, your final option is to seek an external review of the internal appeal. You may qualify for an external review if your health plan’s denial involves a difference in medical judgment between your doctor and your health plan; or if your health plan asserts that the prescribed treatment is experimental or investigational. If you believe that your case qualifies for external review, make sure to check your insurance plan to see how your insurer participates in an external review process (different companies have different processes). Look at the information on your Explanation of Benefits (EOB) or on the final denial of the internal appeal by your health plan. It will give you the contact information for the organization that will handle your external review.
For more information on how to file an appeal, visit the appeals page on HFA’s website.
If you have health coverage through Medicaid, again make sure to work with your doctor to make a medical case for using the non-preferred product. Your doctor and/or clinic staff should be able to counsel you on how to access treatments on the non-preferred list in your state.
Even if you find that your health plan will not allow you access to a clotting factor product that you need, please let HFA know by completing Project CALLS! Together, we can build a case for change.
Sincerely,
Addy
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HFA frequently receives questions from the bleeding disorders community related to advocacy issues. The questions often impact the entire community. In an effort to reach the largest audience possible with our responses to these widely applicable questions, HFA developed “Dear Addy.” Questions submitted to this column are edited in order to protect privacy and should be considered educational only, not individual guidance.