We have all had frustrations getting healthcare paid for, whether it is getting access and coverage for appointments, procedures, equipment, and/or medications.
Coverage is especially difficult when new medicines or procedures are recommended. Parents, patients, and medical providers spend hours putting together documents and speaking on the phone trying to convince payers that this is what is needed to keep us, our children, or our patients, as healthy as possible.
It's a complicated and often an overwhelming process that makes you just want to throw in the towel. But we can’t. What is important to know is that this is a process and policy determinations are not always final.
To make this process easier, PPMD has assembled resources that will help families and medical providers at each stage of the healthcare access process. Included below is a road map aimed at guiding you through this complex process – complete with sample letters and links to relevant publications and other resources.
We are working closely with health insurance payers (public and private) to increase their understanding of Duchenne and how access to available and emerging interventions, therapies, and equipment can improve health outcomes for our community.
As our engagement continues and we learn more, we will update and produce additional tools and resources for utilization by our community.
Access to Medicine Process
The process for access to new medicines is not always linear. If your plan does cover the medicine, there are programs available to limit your out of pocket costs.
Below are resources outlined for each stage of the process, including if a denial occurs.
How do I start the process for access?
To begin the process for access, most drug companies have a start form that can be filled out by you or your physician.
Some insurers will require what’s called Prior Authorization. This may involve confirmation of genetic test results and other medical records to be submitted with the prescription from your doctor.
Your clinician will be a key advocate for this process. He/she should consider submitting a Letter of Medical Necessity (sample letter below), which provides background information about the patient, disease, and drug.
Stage 1 Resources:
SareptAssist Patient Services Overview [PPMD Webinar Recording]
What happens if access is denied by my insurer?
It is at this stage a complication could occur.
If you receive a denial, there are steps you can take in order to appeal the decision. Your clinician will be a key advocate in this process. The denial letter should have specific information about the appeals process.
The clinician or doctor can request what is called a "peer to peer" where your clinician will interact directly with the insurer one-on-one to provide justification for access and coverage.
Things to Consider:
Tips for Advocating for Access:
Stage 2 Resources (If you receive a denial letter):
Dr. McDonald has graciously shared the data and presentation that was compiled for their successful engagement
with MediCal and recorded an explanation of the data and the context of the engagement, as well as details as to how he and his team have been engaging with private insurance companies and empowering families to work with insurers. Special thanks to Dr. John Day, Dr. Perry Shieh, and Dr. Chamindra Konersman, for their contributions to this effort.