The first step in determining your access to a drug is to check the available coverage through your drug plan. If you use a private insurance drug plan, this may require going on-line or calling the insurer.
It is important to note that the insurance provider will only release information about the plan to the plan member, and only information on the plan that is relevant to that plan member.
You may wish to call the insurer on your own, use the member section of the insurer’s website, or the insurer’s app. The phone number and website information can be found on the back of your insurance drug card or your policy information booklet.
Before You Call
- Look at your drug insurance card or the plan information you received at the time your policy started; if you cannot locate this information, and your plan allows for direct billing from the pharmacy, call the pharmacy to retrieve the information they have on file
- You will need the name of the plan member (you, your parent or your spouse/partner), the plan member’s date of birth, the group or certificate plan number, and your member or identification number
- You will also need the name of the drug and the DIN for that drug
During the Call - Questions to Ask
If the drug is listed on the plan, you can proceed to the next questions. If it is not, it is important to ask if the drug is a “non-benefit” or if it simply does not appear in the plan’s list of drugs. If it is a “non-benefit”, then usually the plan is not designed to include that type of drug, or the drug was reviewed, and a decision was made not to cover it. If the drug simply is not in the computer system, (1) check that the person has the spelling and DIN number of the drug correctly typed, (2) check to see if other formulations of the drug are covered (if so, it may be simply that your type of formulation is not in the database but may be considered for coverage), and (3) check to see if the drug has yet to be reviewed by the plan. If the drug is new, it may be that the plan simply hasn’t listed it YET. If this latter point is the case, you may want to consider submitting a letter of request for coverage to the insurer.
A drug may be listed on your plan as requiring “Prior Authorization”. This means the insurer will only cover the drug for certain clinical conditions and will need to review your request before coverage will be approved. If you find out Prior Authorization is required, ask if the form is available on the insurer’s website. If you are on the phone with a PSP representative or oncology drug access navigator, they may have the form already. You will need to complete and sign the Plan member section of the form. It is also helpful to ask the insurer how long the current processing times are for Prior Authorization forms.
This is a good question to help you figure out how much you will have to pay out-of-pocket for your drug. Every plan is different. Some only require a set amount be paid for each prescription (e.g. $5 or $10) while other plans require the plan member to pay a % of the cost. If the latter applies to you, and you feel the copayment will be unmanageable for you, speak to the oncology drug access navigator or PSP representative after the call about co-payment assistance options.
A plan maximum is the amount the insurer will pay, in total, on your prescription drugs in a year or a lifetime. Some plans have no maximums, but it is important to ask. If the treatment drug you need is a higher cost drug, it could impact your coverage. For example, if you needed a drug that cost $5000 per month but you only had $25,000 in annual coverage available, you would run out of coverage for that drug and all other prescription drugs within 5 months. The information on plan maximums is not always available from the member section of an insurer’s website but can be found in your policy booklet.
It is helpful to write down the name of the insurance plan representative that you are speaking with on the phone, the date and time of the call, and any information provided to you on processing times for paperwork. This can be helpful if your request for coverage is delayed or denied.
The Oncology Drug Access Navigators of Ontario (ODANO) has produced a helpful video that illustrates some of these points.
After the Call
- If you have been completing the call as a 3-way call with your oncology drug access navigator or PSP representative, before you hang up review the information you heard with that person.
- Ask that person about who is responsible for completing any forms, and how you will complete and sign your section of the form.
- If there are concerns about deductibles or copayments, ask that person what options for financial assistance may exist.
- If the drug was not covered by the plan, ask if there are other options available that will allow you to start the drug on time.
- Set a follow up appointment with that person to follow up on paperwork or any other arrangements.
- Finally, confirm the start date for the drug that you were given by the oncologist. It is important that all those involved understand the start date and this is adhered to strictly, even if coverage is approved and drug is sent to you ahead of that start date. If you anticipate that coverage will take longer to arrange and it may push the start date later, notify the prescribing doctor.
Submitting a Prior Authorization Request
A drug may be listed on your plan as requiring “Prior Authorization”. This means the insurer will only cover the drug for certain clinical conditions and will need to review your request before coverage will be approved.
Your Oncology Drug Access Navigator or patient support program representative will coordinate any prior authorization form(s) required and will follow it up. You will need to complete and sign the Plan member section of the form before it is sent. You will be notified by the insurer if they have questions or when a decision is reached. If you receive a decision from the insurer by email or mail before you hear from the Oncology Drug Access Navigator or PSP representative, contact them with the information.
If Your Drug is Not Covered
Your drug plan may not cover the drug you need. Next steps depend on the reason that you are provided by the insurer:
- If a drug was already reviewed by the insurer and a decision was made NOT to add it to your plan, then it is considered a “non-benefit” (see “Is the drug listed on my plan” above). Most decisions on non-benefits are final, so to have it reconsidered can take awhile. In the interim, you can work with your oncology drug access navigator to look at public drug plan options or other PSP options.
- At your discretion, notify your employer or benefits manager that the drug was not covered as a benefit on the plan. Some employers have mechanisms to reconsider coverage of certain drugs, and some do not, leaving it to the insurer’s evaluation.
- It may be that your employer offers several different plans that offer different levels of coverage (e.g. bronze, silver, gold levels). If this is the case, you may want to speak to your employer to see if you can enroll in a higher-level plan that might offer you coverage of this drug. Weigh the pros and cons of whether the higher premiums will be worth it!
- Your oncology drug access navigator will review the prior authorization form to ensure the physician completed all sections of the form correctly; too often, patients are denied coverage because a piece of information was missing or misunderstood; if there was an error, the oncology drug access navigator will have the physician call the insurer or will re-submit the form
- If the information was correct but the insurer felt you did not meet the clinical criteria for coverage approval, the oncology drug access navigator will ask the prescribing physician to review the decision; if the physician feels the insurer is using out of date criteria or has misunderstood something in their interpretation of the information, the physician may want to make a direct appeal for a review of the request; usually, this review is conducted by a supervisor or other person at the insurer, not the original reviewer
- If the information was correct but you are missing key pieces of information for the insurer’s review due to a poor biopsy sample, inconclusive test results, etc. then the oncology drug access navigator may speak with the prescribing physician about other information that could be submitted, additional tests that could be performed or re-done, or whether the physician wants your request to be reviewed by the insurer with an additional explanation about why samples or tests were incomplete
- If the Prior Authorization was declined because the drug is being prescribed for “off label” use and does not fit the insurer’s clinical criteria for use, then the oncology drug access navigator may ask the prescribing physician to look at other treatment options or in certain cases may speak to the pharmaceutical company about a compassionate supply.
- If the request for coverage is STILL denied after repeated clarifications or attempts for review, then the physician still has the option to write an appeal letter to the insurer. Your oncology drug access navigator can guide the physician through this process.
- You also have the option of notifying your employer or benefits manager about the denial and ask for a review of the case. Some employers have mechanisms to reconsider coverage of certain drugs, and some do not, leaving it to the insurer’s evaluation. If you are part of a union, you also have the option of informing them of this process.
- Occasionally, an insurance plan may refuse to cover a drug because it is listed on a provincial drug plan. The insurer may stipulate that you must apply to that drug plan for coverage FIRST. This is an unfortunate trend, because what many insurers do not realize is that provincial public drug plans often require paperwork and sometimes a fee for a person to enroll. The time required for this often wastes time and delays treatment.
- Your oncology drug access navigator will speak to the insurer and explain the structure of the provincial plan and will discuss if application to the provincial drug plan is relevant. This may include sending the insurer documentation to demonstrate this point.