Как возможно получить Insurance Approval на лекарство, которое страховка отклоняет

[Torma]

Наконец получила одобрение страховки на лекарство, которое она отклонила при первом обращении.
Пришлось, вступить в диалог с докторским офисом, который, судя по всему, после отклонения лекарства страховкой в первый раз, просто drop it, не поставив в известность ни врача, ни пациента. При этом не был сделан офисом Prior Authorization лекарства, что было необходимо. Разобрались наконец.
Одновременно на месадж борд, на которую я подписана, одна дама, которая работала волонтёрам и помогала получать пациентам одобрение от страховок, поместила следующую информацию, которую, как обещала, я публикую и выношу из своей другой темы. Может кому пригодится.

Towards Insurance Approval:
1. Get Pharmacist Involved.
If your doctor is at a health care institution with a pharmacy included, ask if they have a “Specialty Pharmacy Liaison” or something similar on staff. If yes, that’s great. Get their help. They should be the main person doing a lot of leg work on this, given specialists are so busy. They often then act as your contact point and give you an estimate of turn around time and an update on the outcome of approval, appeal, etc.
2. Get an insurance case manager. Talk Dollars Saved $$$
An insurance case manager works within the insurance company and their function is partly to try to minimize costs and payout from the insurance company. If the insurance case manager can make the case that being on this possibly more effective treatment option at the higher dose may result in your disease activity being better managed, thus keeping you out of the hospital and ER, that may help.
3. Escalate. With Insurance, Specialist, whoever needed.
Call the insurance company and talk to whoever you can. If you haven’t talked to a complaint department yet, see if they have one and get something filed there. Escalate within departments you’ve already contacted by asking for supervisors or managers or an escalations agent. If there’s any doubt of your specialist’s commitment, ability, bandwidth, loop in help from pharmacy as mentioned, but also escalate to another provider or ask for the clinic manager’s input. Hopefully, less relevant for you, but doing so can add a touch of accountability to the provider or possibly more in-clinic support. I’ve seen this method occasionally get tests ordered and surgeries done, etc.
4. Update and Communicate All Diagnoses
Say, you have a disease D, and you have that documented and they approved the D dose not the higher dose. Are there any other potential diagnoses that you might need to make sure are updated or documented? Are you allergic to any components of other med options?
5. Eliminate Alternate Drug Options & Communicate Drug Safety Factors.
Are there any safety factors that would rule out other meds that you haven’t already failed? Example: Getting a TPMT blood test can determine if some MED is safe for someone to take or not. It’s rare, but if the test comes back showing that you cannot safely process MED, then it is crossed off of potential medications to take/meds that would need to be failed before escalating to other med options.
If you are now or soon considering any change in your life or health that could affect medication choices, communicate those. Examples: Are you now or soon considering attempting pregnancy? If you are, that would cross out several medication options that an insurance company may want you to try first and fail. While any medication can carry risks, some are stoutly in the danger zone for pregnancy. While the ones considered safe may still carry risks.
Side note: If a provider ever seems hesitant to prescribe certain medications due to a patient being in their fertile years, communicating that you are not going to attempt pregnancy can also open up a lot of medication options. Some providers will either outright or unconsciously let a patient’s fertility status effect their treatment recommendations. This is also common outside of medication decisions with other types of care choices, like gynecological surgeries etc.
6. Get Very Specific & Keep Asking for Help.
The title of this tip makes the main point. Example: Share the name of the insurance carrier in a post like this in case a reader has experience with that company, etc. The fact that you thought to post here is great and an example of asking for help. Do so offline too in case someone you know may have a good idea. Example: Not medical, but when I lost my cat I incorporated it into every convo in case people would have tips… and understand why I was fraught with worry and carry a can of sardines everywhere I went lol. Anyways, a pool supply store employee gave me the tip to contact animal control and ask them for advice. I did so. The animal control agent got info from his girlfriend in cat rescue; she suggested using Kentucky Fried Chicken as a lure in a humane cat trap, they used it for tough to find/catch cats. Guess what? My cat came was captured after being lost for 17 days.
7. Publicize.
This is a personal decision, but in some rare cases leveraging social media or the press has led to reversals of insurance denials. Example: Shane and his wife Sara fought several rounds of denial for Shane’s robotic wheelchair arm, cost in the tens to hundreds of thousands of dollars. Shane has Spinal Muscular Atrophy.It was an assistive device and not a medication, but takes anything that strikes a chord as a tip. Shane and Sara created a packet that had multiple letters of support for his requests from doctors, other professionals involved in his care, and also impact statements from his family members. I recall that they made points about quality of life and also safety and improving outcomes. Shane and Sara published a YouTube video and post on other social media platforms. Shortly after, the denials stopped and he received approval. It helped that they had a large social media audience already, but some health care institutions, drug companies, and less commonly insurance companies have complaint/grievance/escalations/retention departments that review social media for potential bad PR periodically/to different degrees. I have seen positive action taken for lesser known people who post too.
8. Get Family Support. Get anyone’s Support.
See the example in 7 about Shane and his wife and others who helped him. We all have varying support and amounts of people in our lives, but if you think anyone can help you with morale, to dos around this, or they might know someone who can, go ahead and ask/mention it. This relates well with point 6 too. Some find professional, paid for health advocates helpful. It’s rare, but some patient relations or in house patient advocate type employees at the hospital or doctor’s office will get on the phone with insurance companies to pin down tricky billing situations or approvals that other departments have abandoned or that have fallen through the cracks.
9. Tip for Next Time. Get Ahead of the Denial.
Some specialists expect to get denied for a medication and it will even influence what they prescribe or do. This is a hard part of the system, especially in the US. Expectation of failure can lead to or guarantee failure. This is seen in the example shared already of insurance companies' broad, aggressive denial policies knowing it will automatically cut out a huge percentage of prescriptions/actions, because patients or providers will not appeal. It can also show up in a provider who doesn’t think to submit plentiful materials and reasoning along with the initial request. So the tip is, for providers to submit and go all out on documentation right from the start.
10. Prepare, Document, Ask.
Make notes on what your goal is and any details before communications related to this. Document everything, dates, times, people spoken to. Ask “Why” to anything you need to, as others have said: Ask the insurance company why they are denying. If broad statements are made, ask for more specifics. Ask for names of those involved in decisions.
Bonus Tip
11. Contact Manufacturer. 
As others have said, contacting the manufacturer for either discount, help with supply, or asking them for tips on maneuvering insurance can be great.

[PAF]

Спасибо за информацию, будем иметь ввиду, только вчера вот была такая ситуация, выручила фармацевт, которая дала какой-то купон и лекарство с $600 ушло в ноль

[shokoladnitsaa]

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