Many patients face difficulties when it comes to understanding medical insurance.
When determining if the medications and treatments they need are covered by their insurance, it becomes even more confusing.
“Many treatments -- in particular intravenous treatments used for hemophilia -- are covered under a separate part of an insurance plan, not the pharmacy plan,” Katie Verb, associate director at the Hemophilia Federation of America (HFA), told Patient Daily. “Details of medical-benefit drug coverage can be difficult for a patient to be well-informed.”
Verb explained that the information is important to know because the drugs tend to be costly, so if they are not covered, patients could have to pay out of pocket, switch to different, less effective treatments or appeal to the plan. Furthermore, searching for what is and is not covered can be a daunting task for a client.
When asked about why the differences matter, Verb explained that medical-benefit drugs are “mainly complex treatments that are infused or injected in a medical setting, such as a doctor’s office or chemotherapy clinic.” In contrast, pharmacy-side drugs are generally pills or are self-administered injections.
“The classifications of drugs, especially if labeled ‘therapeutic class,’ or generic names of medications, which can be more affordable, but not always covered by pharmacy plans, can be confusing for consumers,” Verb said.
“I haven’t been able to find that and I do this for a living,” Verb said. “Even insurers admit the difficulty in finding the information about intravenous drugs covered under the medical benefit.”
Verb further explained that in doing a search, consumers might need to know to which “therapeutic class” their drugs belong, as well as their generic names.
“Even then, the information might not be available online,” Verb told Patient Daily. “Furthermore, insurers’ information lines may not always be able to provide information about benefit drug coverage.”
Verb, along with other supporters, believe information about medical-benefit drugs should be transparent, with new laws requiring insurers to provide “information sufficient to determine whether a specific drug is covered when furnished by a physician or clinic.”
HFA director supports prescription drug transparency to avoid costly treatments