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Health Care Reform:

Health Insurance & Affordable Care Act

When insurance refuses coverage, drug companies may help out.

Getting the Care You Need

A Little-Known Secret continued...

Biotechnology giant Amgen will, in some cases, take a more direct approach. "We do have people who try to help [patients] work through their insurance reimbursement challenges, which includes contacting payers on behalf of those patients," says an Amgen spokesman. And in the case of Epogen, Amgen will give patients who qualify subsidies, or sometimes even provide the drug at no cost.

The aim of such assistance programs is to provide the estimated 44 million U.S. residents without sufficient health care coverage a way to receive treatment for chronic illnesses -- with the drug company absorbing most or all of the cost of a medication.

Why Insurance Companies Refuse Drug Requests

There are a variety of reasons why a patient may be refused coverage for a drug. These include ambiguity in the prescription for a medication that has multiple uses. For instance, the skin cream Retin-A can be used cosmetically to treat wrinkles and medically to treat acne, but it may also have other "medically necessary" uses. A health plan may need clarification that the use is not a cosmetic one. In this case, the question of coverage can be resolved without a drug company's help.

Advocacy often comes into play when drugs are new or are being prescribed for new uses. In these cases, a health plan may regard the drug as experimental -- not part of mainstream medicine -- and decline coverage based on policy exclusions.

When a patient is refused coverage for a medication, the drug maker often will help in the appeals process by making phone calls to determine what a patient's policy will and will not cover, and by working with the doctor to write a letter of medical necessity. In the latter situation, the drug company may provide additional information about how a medication works and its effectiveness, including sending the physician journal articles to help support the appeal.

Programs Support Those in Need

Chief among those who must turn to these patient assistance programs are professionals on the frontlines of medical care for the financially needy -- pharmacists in free clinics, who give the programs glowing reviews.

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