Your insurance may require a referral to the office for a specialist, especially if the physician is a Pediatric Rheumatologist who may be out of network. Your health plan may require you to get a referral as a part of the benefit coverage – not getting a referral when you need one could lead to a) benefit coverage not being available b) your benefit may be limited or considerably reduced c) you may be subject to higher cost sharing d) you may end up having to go through an administrative appeal process to get the coverage. It is important for you to know the requirements of your Health Plan and make sure that you (or your physician on your behalf) follow them.
Many insurance companies require prior authorization for biologic and injectable medications such as Enbrel, Humira and some high cost oral medications. They may also require the medication be shipped to you via a specialty pharmacy. Also, your pharmacy may be out of network for your insurance. Your pharmacist and your insurance company should be able to tell you why, and if the medication(s) needs to be filled elsewhere, like a mail-order pharmacy, and if the medication needs a prior authorization. Medications may need pre-authorization due to formulary status, being an injectable drug, or seeking exception due to multiple reasons.
Always keep your insurance information updated with your physician office and pharmacy. Always keep in mind that when you go through a benefit renewal, even if you did not change the plan, the process to access your benefits may have changed.
Know that you may need a new authorization due to a multitude of reasons – most common being; if you change physicians, pharmacy or health plan. Or in some cases when your health plan changes their specialty pharmacy. Contact your insurance company. Inquire if the medication needs a prior authorization and if it needs to be filled by a specialty pharmacy. Keep in touch with your pharmacy regarding the status of the prescription. Call your doctor’s office if a prior authorization is needed or if the prescription needs to be sent to a different pharmacy. Ask your doctor/nurse if the medication has a copay assistance program. Many drug manufacturers offer programs to ensure the patient is able to receive medication.
Contact your insurance company and/or your Human Resources at your employer. They may offer a Case Management nurse, Care Coordination resources from a Pharmacy Benefit Management company and/or Patient Navigators from your employer.
For additional Resources or support, please contact our Director of Strategic Partnerships & Patient Engagement, Vincent Del Gaizo, at [email protected].