Tips on Securing Reimbursement for Medications

Educational Objectives

The goal of this program is to improve reimbursement rates for prescribed treatments. After hearing and assimilating this program, the clinician will be better able to:

1. Guide patients in finding assistance programs for uncovered medical expenses.
2. Navigate the prior authorization and appeals process for treatments denied by a patient’s insurance company.

Summary

Definitions: formulary — list of drugs covered by insurer; prior authorization (PA) — process that requires providers to submit information before insurer provides coverage of product or service; step edit or step therapy — treatment or treatments that must be tried and fail before another treatment can be approved; quantity limit — amount of product allowed per unit of time; site-of-care optimization — redirection of services to setting with lower cost to insurer

Appeals: first- and second-level; peer-to-peer — provider-to-provider discussion (typically by telephone); independent medical review — review at state level after exhaustion of grievance process with insurer

Assistance programs

Needymeds.org website: provides information on all available assistance for any drug; assistance with copays — assistance besides what insurance pays; available from manufacturers for brand name infused or injectable biologic agents, small molecules, and some biosimilar agents (government-funded plans excluded); assistance programs for patients from manufacturers — provide full-cost assistance for drug if requirements met; may require submission of authorization and denials of appeals; infusion costs associated with drug not covered (insurance coverage as medical benefit or payment out-of-pocket required); independent patient assistance programs — funded entirely by donation; availability limited

Goodrx.com website: provides lowest cash price for medication based on patient’s zip code; independent of insurance

Insurance coverage: medical insurance — covers items given within health care facility; pharmacy benefits — managed by pharmacy benefit manager (eg, Express Scripts, OptumRx); typically separate from medical plan; cover items that patient self-administers; some benefits covered by one plan become carve-outs (exceptions) on another plan and require different coverage (eg, infusions covered by pharmacy benefit, injectable medications covered by medical benefit); requests for high-cost medications may require authorization from utilization management department of medical group

Medicare: original plan — red, white, and blue card; Part A and Part B cover hospital and medical expenses; Part D — patients opt in for prescription coverage for self-administered medications; entirely privatized, but follows guidelines of Medicare; Medigap plan — supplement to Medicare plan; privatized; covers items not covered by Part A or Part B; Medicare Advantage plans — patients sign Part A and B benefits over to specific plan that administers all benefits; may include coverage for outpatient drugs; high copays for some self-administered medications — allowed by Part D plans established by Medicare; Part B plan plus supplement may be used for more cost-effective administration of medication in infusion center (Part B pays 80%, and Medigap typically pays 20%)

Process for PA and appeals: PA form and information submitted to payer; payer reviews information and may request additional information; makes determination and contacts office and patient; if approved, prescription filled; initial PA denied — submit appeal in writing or for peer-to-peer review; payer makes decision; appeal denied — go to manufacturer for assistance, or continue process with insurance (enter second-level appeal in writing or with peer-to-peer review); payer makes decision; second appeal denied — pursue independent medical review by state, or wait 6 mo from initial submission and start process over from beginning; clinical impact — PA process enduring; treatments often approved if process followed, but process not efficient and takes unreimbursed time from practice

Management tips: maintain familiarity with common insurance plans — gather formularies each calendar year; contact manufacturers — information about plans covering a manufacturer’s medications without step edits available; collect information on patients’ pharmacy benefits at check-in — educate staff; put procedures in place; include documentation in chart — clinical decision making; diagnosis; current symptoms and recent imaging; past tried and failed treatments, approximate dates of each intervention, and doses; why treatments failed (eg, no response, partial response, adverse effects); treatments not tried, but inappropriate, and why (eg, allergies, intolerances); past medical history (eg, cardiac or cancer history); physical and cognitive capabilities for using different products; pharmacokinetics; lifestyle (eg, travel, work, exposure to sun, risk for infection); preferences or refusals; access to refrigeration; mailing address; assign responsibility to staff member — person need not be on clinical staff; role requires organization, effective communication, training in terminology and process, compassion, patience, and good follow-through; alternatively, patient can self-advocate; additional documentation — all submissions; keep denials and approvals in file; allot time for PA and appeals

Encouraging involvement of patient: be honest — do not promise specific agents without knowledge of insurance coverage; provide education on PA process — PA takes ≤14 days; appeals, ≤30 days; Crohn disease and ulcerative colitis websites provide education for patients; use available resources — prescribing information for brand name drugs available online; infusion centers often manage PAs for patients; contact manufacturers for forms and individual representatives to meet with staff, provide templates for letters of medical necessity, and offer educational materials; electronic PA — portals save information on providers and patients; allow easy submission and tracking; save templates — post templates for easy access

Readings

Corder JC: Streamlining the insurance prior authorization debacle. Mo Med, 2018 Jul-Aug;115(4):312–4; Jones LK et al: Understanding the medication prior-authorization process: A case study of patients and clinical staff from a large rural integrated health delivery system. Am J Health Syst Pharm, 2019 Mar;76(7):453–9; Neuman P, Jacobson GA: Medicare Advantage checkup. N Engl J Med, 2018 Nov;379(22):2163–72; Popatia S et al: Examining the prior authorization process, patient outcomes, and the impact of a pharmacy intervention: A single-center review. J Am Acad Dermatol, 2019 Dec;81(6):1308–18.

Disclosures

For this program, members of the faculty and planning committee reported nothing to disclose.

Acknowledgements

Dr. Whitmire was recorded at New Advances in Inflammatory Bowel Disease, held September 14-15, 2019, in San Diego, CA, and presented by Scripps Health. For more information about upcoming CME activities sponsored by Scripps Health, please visit scripps.org. The Audio Digest Foundation thanks the speakers and sponsors for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

FP684501

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.