Update from PTC Therapeutics - FAQs for Patients and Families:
Will my insurance cover EMFLAZA™ (deflazacort)?
Each patient may have a different insurance plan. In order to determine the insurance benefit for any patient, a completed EMFLAZA Prescription Start Form must be submitted to EMFLAZACares™. This form is available at EMFLAZA.com.
After the EMFLAZA Prescription Start Form is submitted, your EMFLAZACares Case Manager will work with your insurance plan on your behalf to verify your insurance benefit.
Insurance providers may require more information from your physician about the medical necessity for EMFLAZA. Your EMFLAZACares Case Manager will work directly with your healthcare provider to submit all information necessary to answer questions from your insurance provider. We expect that going through this process with your insurance company may vary from days to several weeks, depending on your insurance plan.
After insurance coverage is approved, how long will the prescription continue?
The length of time the prescription is active will vary by insurance provider. Most insurance providers
authorize prescriptions for six months to one year. Your EMFLAZACares Case Manager will monitor your prescription and will apply for reauthorization before the prescription expires.
How much will I have to pay for my prescription?
Each patient may have a different insurance plan. The specific benefits of that plan determine the amount paid by your insurance provider and the amount that you will pay.
In order to determine the insurance benefit for any patient, a completed EMFLAZA Prescription Start Form must be submitted to EMFLAZACares.
At that point, your EMFLAZACares Case Manager will work with your insurance plan on your behalf to verify your insurance benefit to determine coverage, including any cost assigned to the patient. The type of out-of-pocket expenses may include a copay, coinsurance, and/or deductible.
PTC has created comprehensive patient assistance programs to provide you with the financial safety net needed to ensure access to EMFLAZA.
Your EMFLAZACares Case Manager will determine which patient assistance program is right for you, based on your type of insurance
PTC is committed to minimizing or eliminating all patient out-of-pocket expenses.
Private or Commercial Insurance
If you have private or commercial insurance, your EMFLAZACares™ Case Manager will automatically enroll you into a program that will eliminate your cost in most cases. Some state regulations mandate a patient pays a small amount (such as $10) each month. In those cases, patients may have a small monthly payment.
Public or Government Insurance
If your insurance is provided by the government (like Medicaid or Medicare), you may have to pay a certain amount out-of-pocket. In these cases, your EMFLAZACares Case Manager will refer you to a third-party patient foundation that will work with you to provide financial assistance based on your eligibility.
If you do not have insurance coverage, your EMFLAZACares Case Manager will offer EMFLAZA™ (deflazacort) free of charge if you meet eligibility criteria.
REMEMBER: In order for your EMFLAZACares Case Manager to help, a completed Prescription Start Form must be submitted to the EMFLAZACares program. The form can be found on EMFLAZA.com.
If a patient is already on deflazacort, including as part of a clinical trial, will he be required to discontinue deflazacort or switch to prednisone because of insurance requirements?
PTC is committed to continuity of care. We have a Bridge Program in place so that any patient currently taking deflazacort can continue on EMFLAZA while waiting for insurance verification of coverage for EMFLAZA. In order to start this process, there must be a Prescription Start Form submitted. This form can be found at EMFLAZA.com.
What is the difference between EMFLAZA™ (deflazacort) and prednisone?
EMFLAZA is approved by the US Food and Drug Administration (FDA) for Duchenne muscular dystrophy in patients 5 years and older. Prednisone is not approved for Duchenne muscular dystrophy.
Can you explain weight-based pricing?
The recommended oral dosage of EMFLAZA is approximately 0.9 mg/kg/day once daily. In other words, the dose of EMFLAZA is calculated based upon the weight of the patient. Once a dose is determined, the necessary tablet strength(s) is used to reach that dose. Each tablet strength, as well as the oral suspension, has a specific price.
Will getting insurance coverage of EMFLAZA cause my insurance premiums to rise?
While it is impossible for us to predict what factors influence healthcare premiums, the impact of EMFLAZA to an insurance plan’s budget is negligible. It is not expected that premiums for prescription coverage will increase due to EMFLAZA.
How will you supply EMFLAZA to patients who received deflazacort from Masters Pharmacy?
PTC has an EMFLAZA Bridge Program in place to provide deflazacort to anyone previously receiving deflazacort from Masters Pharmacy until they receive insurance approval. Under the EMFLAZA Bridge Program, patients will receive EMFLAZA free of charge while they are waiting for insurance approval.
REMEMBER: To get started, make sure that both you and your healthcare provider sign the Prescription Start Form and submit the form to EMFLAZACares™. This form is available on EMFLAZA.com.
How do I find out the status of my approval?
Your EMFLAZACares Case Manager will keep you informed of the progress of your application. You may call 1-844-EMFLAZA for an update.
How will I get EMFLAZA?
Once approved for EMFLAZA, the pharmacy (US Bioscience) will call you to arrange delivery. EMFLAZA will be delivered to your home, office, or other location of your choice.
How much EMFLAZA™ (deflazacort) will be shipped to me?
Generally, insurance companies authorize shipments of a 30-day supply. However, some insurers will approve a 90-day supply. You may discuss the shipment approved by your insurance company with your Case Manager.
How do I order refills?
The pharmacy will call you to schedule your refill. You can also call 1-844-EMFLAZA if you have any questions about your refills.
What if I don’t want the services of EMFLAZACares™?
If you choose not to sign the Prescription Start Form and enroll in EMFLAZACares, your prescription will go directly to the pharmacy (US Bioscience). The pharmacy will determine your insurance coverage but will not be able to help you with appeals if coverage is denied. They will not be able to enroll you in any of the programs PTC has in place to reduce out-of-pocket expenses.
Where can we get more information?
More information can be found on EMFLAZA.com. Case Managers are able to assist you and can be contacted at 1-844-EMFLAZA. They are available 8:00am – 8:00pm EST, Monday – Friday.