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.
"Medications would be prohibitive for us to purchase; we're the largest free clinic in the country with 16,000 to 20,000 patients a year," explains Ruth Smarinsky, PharmD, director of pharmacy services for the Venice (Calif.) Family Clinic.
Pharmacies at these clinics, which serve the working poor, do not have a ready supply of drugs to fill prescriptions immediately. Medications are obtained on a patient-by-patient basis, and patients must often wait three to four weeks to receive them. The majority of the programs give a patient enough medication to last three months.
To fill the gap, Smarinsky says the clinic relies on free samples that drug company representatives bring with them when they visit the clinic. The reps make these visits fairly often, because the Venice clinic sponsors a residency program that includes 500 volunteer physicians. "[The drug rep visit] is inexpensive marketing for [the company]," says Smarinsky. Although obviously beneficial for clinics and patients in some situations, such close collaboration between health professionals and drug companies remains controversial. (See A Prescription for Trouble)
In return for the drug rep's one-stop office visit, Smarinsky gets what her clinic needs -- a way to help bring relief to clinic patients while they wait for their prescription drugs to arrive. "We wouldn't have a pharmacy without the samples or the [patient assistance] programs," she says.