Third Party Financial Approval for PAH Medications

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Often when patients discover the cost of pulmonary hypertension (PH) specific drug therapies, the initial reaction resembles: “There is no way I'll ever be able to afford this.” The clinician must reassure them that insurance companies usually cover these medications and explain the process of obtaining them. Other options may also be discussed if, by chance, their insurance company does not cover the prescribed drug.

The first step in the approval process is securing a prior authorization. Most patients are not familiar with what a prior authorization is or how to go about accessing one. This process can be quite daunting, but if you familiarize yourself with the questions asked most frequently by the insurance company, the process tends to go relatively smoothly. Due to the high cost of PH specific drugs, insurance companies want to be certain the diagnosis of PH is accurate and that these medications are appropriately prescribed and monitored. The questions most frequently asked by insurance companies vary and include the following. 1) What is the WHO group classification and/or WHO functional class? 2) Has the diagnosis of PH been confirmed with a right heart catheterization? 3) Is the prescribing physician a cardiologist or pulmonologist? 4) Has the patient been prescribed a calcium channel blocker? Once a prior authorization has been secured, some insurance companies mandate that the patient receive the medication from one of several specialty pharmacies: Accredo, CuraScript, and Caremark are the most common. When a specialty pharmacy is used, the drug is dispensed and sent directly to the patient's home. In some cases, the specialty pharmacy will contact the patient monthly to ensure he/she has received the FDA required monitoring and if not, medication shipment will be delayed.

Sometimes, even after following the process and meeting the criteria, an insurance company will still deny the request, and an appeal letter must be sent. The appeal process can be lengthy depending on the insurance company, and usually requires the prescribing physician's office to submit further clinical documentation as support. While waiting for the appeal to be reviewed, there are programs that can help provide medications to patients until they receive approval. Sometimes coverage will still be denied, or the patient will have an unusually high co-pay or be in the “donut hole” and still have to pay the full price of the drug. At this point, it is best to connect the patient with one of the many available assistance programs. Many patients are reluctant to apply to these programs, as they either do not want to submit their financial information or they believe that their income level is too high or they have too many assets. These patients should still submit the application; each program has income guidelines that vary. It is imperative to submit all requested information in a timely manner; not doing so may slow the approval process and delay the receipt of life-saving medication.

These assistance programs are used primarily for phosphodiesterase- 5 inhibitors and endothelin receptor antagonists. When patients require assistance in obtaining any of the prostacylclins, the specialty pharmacies get involved and help patients explore other avenues for assistance.

If the patient has been denied coverage by his or her insurance company and is not eligible for any of these assistance programs, connecting the patient with Caring Voice Coalition, an organization that provides grants for patients to help cover drug costs for certain chronic illnesses, may provide coverage. With the range of assistance programs available, most patients are able to secure treatment options best suited for their situation. Few patients are unable to receive the medications recommended by their PH specialist.

Table. Resources for assistance for PH therapies

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