“Ask a Social Worker” is a regular column featuring questions from the community and answers from members of NBDF’s Social Work Working Group. If you have questions for our social workers, send them to [email protected].
Dear Jackie,
I am currently enrolled in a self-funded insurance plan through my employer. I received a notice that my factor medication is no longer being covered by my employer. A case worker from another company stated that if I signed a form to enroll into the factor medication company’s patient assistance program, I would be able to receive my medication free of cost. What’s the catch?
I know that it can feel stressful to learn that your insurance company and employer are no longer covering your factor medication. It sounds like your employer has opted to use an alternative funding program (AFP), which helps reduce the high cost of specialty medications for employers.
AFPs advise self-funded insurance plans to remove high-cost medications (like factor) from their options of covered medications by categorizing the medications as “non-essential health benefits.” This way, employers are able to avoid high health care costs by redirecting the responsibility of covering certain specialty medications. They do this by contracting with an AFP company that specializes in enrolling employees into factor medication companies’ patient assistance programs (PAPs) so they’re able to receive the medications at a discounted rate or for free.
While this sounds wonderful in theory (who doesn’t want free medication!), alternative funding programs are putting a big strain on PAPs, which are designed primarily for low-income individuals who do not have insurance or are underinsured. The enrollment process and qualification standards are different for each company’s PAP. In general, to qualify for a PAP, you need to be a permanent or legal resident, prove you do not have insurance/are underinsured, and/or meet income eligibility requirements.
You may be denied if your income is too high or if the program sees you have insurance, even if your insurance is no longer covering the specialty medication. Enrolling into a PAP also takes time. So, if you need your factor medication as soon as possible due to a bleed, for example, you might not have access to it right away, which can cause treatment delays and potential harm.
What can you do if this happens to you? First, talk with your employer and see if they can work with you on covering the specialty medication. If your employer-sponsored insurance is still not going to cover your medication, you may need to look into enrolling in another insurance plan. Some examples include your spouse’s insurance plan; marketplace insurance through your state, a parent or guardian’s insurance plan if you’re under age 26; or Medicare if you’re 65 or older and qualify. A final option would be to work with the company who makes the medication and try to enroll in their PAP program.
Finally, your hemophilia treatment center social worker is a great resource to consult for guidance.
-Jackie Bottacari, LCSW
Bottacari is a social worker at the Yale Center for Bleeding and Clotting Disorders in New Haven, Connecticut.