This post presents important information about the types of insurances and reimbursement process for growth hormone treatment from recent webinar “Insurance & Reimbursement – A Turner Syndrome Foundation Webinar” presented by Patient Affairs Liaisons from Pfizer.
What is a Patient Affairs Liaison?
Patient Affairs Liaisons with Pfizer are professionals who are non-promotional employees. Their role is to connect patients, caregivers, and advocacy organizations with various appropriate tools and resources. Oftentimes, they also offer helpful educational program.
This is important to note as the PAL’s presenting this information were not intending to promote or sell a product. Their aim is purely to make helpful information for patients available.
What are the types of health insurances?
There are many types of health insurances, but the three common types of insurances are:
- Commercial Health Plan – is a health insurance plan that you might get through your own employer or your spouse’s employer , or as a part of your family’s plan if you meet certain criteria. You can also purchase it directly from an insurance carrier, or through federal marketplace or insurance broker. It is not funded by the government, however.
- Medicaid – gives health coverage to eligible low-income adults, children, pregnant women, elderly adults, and people with disabilities, using government funds.
- Medicare – is a federal insurance program for people who are 65 or older, certain young people with disabilities, and people with permanent kidney failure.
What are out of pocket costs and why do we have them?
- Out-of-pocket or OOP cost are expenses for medical care that are not reimbursed or covered by insurance. For example, deductibles, coinsurance, and copayments for covered services including all costs for services that are not covered.
- They vary based on the type of insurance and the formulary. Note that a formulary is a list of prescription drugs that are covered under your specific prescription drug plan or on another insurance plan that offers prescription drug benefits. It is usually divided into tiers or levels based on type or usage of a medication and each tier has a particular OOP cost.
What are formulary tiers?
- Tier 4 –
- includes specialty medications (ex: growth hormone treatment)
- consists of medications that used to treat rare, chronic, or complex conditions.
- Tier 3 –
- includes non-preferred medications
- for example, brand-name drugs that are non included on the plan’s formulary
- Tier 2 –
- includes preferred medications
- for example, brand-name drugs that are listed ono the plan’s formulary
- Tier 1 –
- includes generic medications
- consists of prescription drug that has the same active ingredient formula as a brand name drug
What are orphan drugs, and why are they important for us to know about?
- Orphan drugs are drugs that are intended for treatment, prevention, or diagnoses of rare disease or condition that affects less than 200,000 persons in the US and meets certain cost recovery provisions. Growth hormone, which is a specialty medication, is defined as an orphan drug.
- Specialty drugs oftentimes need prior authorizations or approval from a health plan for the order for a service or prescription to be covered by your health plan. So, they are very important.
- Sometimes the policies might require patients to try preferred drugs before the non-preferred drugs are approved for reimbursement by health plans. This is called step edits or “fail first” policy.
What are the key events of the reimbursement process for growth hormone?
- Prescribed Growth Hormone
- Benefits Verifications
- Prior Authorization Submission
- Insurance Decision
- Receive Growth Hormone
If you are interested in listening to the webinar to learn even more about health insurance and reimbursements, please check out the webinar recording!
Written by Dhruvi Patel, TSF volunteer blog post writer and editor.