Many of you have been with the same homecare company for many years. You depend on it to process critical clotting factor orders and make deliveries to your home. The company’s representatives know you personally and handle the submission of costly bills to your insurance company. When your insurance coverage changes and you are forced to switch to a different homecare company, what should you do?
A number of insurance plans and large employers are controlling rising costs for biologics by limiting the number of drug distribution providers. This may include hemophilia homecare companies and your hemophilia treatment center (HTC) if it distributes factor. Increasingly, insurance companies and large employers are only approving one or two homecare company options.
[Steps for Living: Insurance Basics]
Medical providers include hospitals, doctors, physical therapists and hemophilia homecare companies. Providers that contract with and are part of your insurance plan’s approved listing are called “in-network.” The rest are called “out-of-network.” If your insurance coverage or provider network changes, your current hemophilia homecare company may become out-of-network, costing you more.
If you try to continue to use your current homecare company once it’s out-of- network, you may receive significantly reduced coverage or no coverage for your clotting factor orders. You may also have to pay more out of your own pocket.
Here are some tips to help you assess new homecare company options through your insurance company and determine the best way to switch homecare companies.
Hemophilia Homecare Company Terminology
It’s important to know the terms associated with your factor delivery. “Hemophilia homecare company” is a term used by the bleeding disorders community to describe a pharmacy that fills and delivers prescriptions of clotting factor to patients’ homes. Outside the hemophilia community, the term “specialty pharmacy” is more commonly used.
The insurance and pharmacy marketplace generally use the terms:
- Specialty Pharmacy: one that dispenses biotech drugs to treat many chronic conditions, including hemophilia. Biotech drugs are derived from living cell lines, the latest technology, and are expensive. Many biotech drugs, like clotting factor, are infused or injected.
- Hemophilia Specialty Pharmacy: one that dispenses only hemophilia clotting factors. It can be part of a larger specialty pharmacy or operate as a stand-alone.
Many specialty pharmacies and hemophilia specialty pharmacies are part of a pharmacy benefit manager (PBM). A PBM is a manager of retail, mail order and (often) specialty pharmacy drug benefits for employers and health insurers. Your PBM is your drug plan. The three largest PBMs are CVS/Caremark, Medco and Express Scripts.
Understand Your Homecare Company Options With a Change in Insurance
Current Insurance
If your current plan has a change in benefits, have your homecare company verify changes in coverage of clotting factor or in the “in-network” homecare company options.
If your current insurance changes the homecare company options in the provider network, you should receive a written notice (and sometimes a phone call) from the insurance plan. Obtain the contact information for the new homecare company options.
New Insurance
If you have new insurance, verify whether you can use any homecare company or must use a specific homecare company or companies. You can call your insurance plan carrier yourself or ask your HTC, prescribing physician’s office or current homecare company.
Drug Plan Follow-up
If your insurance has a separate drug plan, call your drug plan carrier first. Employers and insurers that contract with or sponsor the drug plan may or may not approve coverage of clotting factor as a specialty pharmacy benefit.
Health Plan Follow-up
If you do not have a drug plan or have a drug plan that does not provide coverage for clotting factor, your health plan will almost always provide coverage for clotting factor as a medical benefit. Call your health insurance company’s pharmacy services or a nurse care manager to determine how your factor is covered.
If it is covered, verify actual benefits coverage and which pharmacy or pharmacies you can use. Get the contact information for the approved pharmacy or pharmacies.
Switching to a New Homecare Company
If you must switch homecare companies, educate yourself about your options so you can make the best, most informed decision for your family. Start by calling the customer service department for each in-network homecare company and visit each Web site.
Review each company’s ability to provide for your needs by asking the following:
- Good Customer Service: How long has the homecare company been in business? How many hemophilia patients does it serve? Who makes up the staff? What is the staff’s experience and knowledge base? What are the hours of operation?
- A Full Inventory of Clotting Factor: How much factor is in inventory? How many different size vials does it have? Are vial sizes of the patient’s prescribed clotting factor in inventory to fill a prescription now?
- All Ancillary Infusion Supplies: Does the homecare company stock a full inventory of infusion supplies, specifically your infusion supplies?
- Disposable Hazardous Waste Containers: Does the company send and receive hazardous waste containers to and from patients’ homes?
- Timely, Reliable Delivery: What is the company’s standard delivery time for an order of an established patient? What express mail service is used?
- Insurance Verification and Timely Insurance Billing: Is there a financial specialist who verifies insurance coverage, bills insurance and clearly explains what the insurance company pays versus what the consumer has to pay?
- “Good” Clotting Factor Pricing: Clotting factor pricing is very important. It may affect your out-of-pocket costs and any insurance annual or lifetime limits that may be applicable.
- Ask how much the homecare company will charge your insurer for factor. However, the homecare company may not readily provide this information. It may require an actual homecare order to verify pricing, or it may have a policy of dealing only with insurers about pricing, because its contract is with the insurers, not consumers.
- For assistance, call a nurse case manager or pharmacy services representative at your insurer (who has a financial interest in controlling costs) and request follow-up with your homecare company.
- Easy Enrollment: What is the procedure to enroll a new patient? After enrollment, how long will it take to verify insurance coverage and receive the first homecare order?
You can find helpful information in “Recommendations Regarding Standards of Service for Pharmacy Providers of Clotting Factor Concentrates for Home Use to Patients with Bleeding Disorders,” document #188 of the National Hemophilia Foundation’s Medical and Scientific Advisory Council (MASAC). You may also want to contact your HTC, NHF chapter, other members of the bleeding disorders community, or HANDI, NHF’s Resource Center.
After You’ve Chosen a Homecare Company
If you have more than one homecare company option, select a new one based on its ability to provide the best customer service and pricing.
Contact the new company as soon as possible. Provide all required information so you can place your first factor order without encountering any gaps in service. New homecare companies will need the following information from you:
- Personal and insurance information
- Medical information about your bleeding disorder diagnosis and your medical history from your HTC or prescribing physician
- A new prescription for clotting factor and infusion supplies
Have the homecare company insurance specialist verify coverage of your factor and your out-of-pocket costs. For coverage or pricing concerns, follow up with your health plan or drug plan.
Your Current Homecare Company Wants to Keep You
Your current homecare company will likely try to keep you as a patient. It will usually ask for your consent to request special approval for you to continue to use it as your homecare company. The company will request to contact either your health plan, your employer—if it is large and self-insured—or, rarely, your drug plan. Authorizing your homecare company to make a special request to your employer means you will likely be disclosing to your employer either your own or your loved one’s diagnosis of hemophilia or another bleeding disorder.
The potential to be granted special approval is greater if your homecare company is a specialty pharmacy of a larger drug plan (with large insurance contracts) rather than a smaller homecare company that only supplies clotting factor (with fewer insurance contracts). If your current homecare company is granted special approval, make sure the insurance coverage is the same as it is for the insurance-approved homecare company or companies. Feel free to call your insurance plan yourself to verify benefits.
Coordinating Transitioning Factor Orders
Notify your HTC or prescribing physician and current homecare company of your insurance-required change as soon as possible. Ask your HTC or prescribing physician to coordinate any needed prescriptions between the last date of coverage with your current homecare company and the first date of coverage with your new company. Make sure you have adequate clotting factor on hand for the transition.
The amount of the final order should be insurance-approved. Your current homecare company, HTC physician or prescribing physician should call the insurance plan to get approval. Insurance plans usually allow for a 30-day prescription—the number of prescribed doses of clotting factor during a 30-day period. The number of doses for the final prescription can be:
- Less than the regular number of doses for a 30-day prescription, depending on when you filled your last order and how much clotting factor you have on hand.
- Increased based on medical necessity—for example, the need for additional clotting factor to treat an active bleed.
If you experience problems with the new homecare company’s service, have your HTC or prescribing physician call the company immediately to fix the problem.
By educating yourself about your insurance coverage and being proactive when a change occurs, you can help ensure that the transition goes as smoothly as possible.