Insurance Woes

Contrary to popular belief, medications in Canada are not free, although there are some Provincial/Territorial programs that provide drug benefits and some versions of Pharmacare programs. You can read an overview of the Canadian system by my fellow contributor, Kerri.

I have been fortunate that I have had some form of medication coverage for quite some time, although there was a significant period in which I have a very limited drug plan that had a particular exclusion of any form of biologic. At this time, I was fortunate enough to have been getting an asthma biologic through a clinical trial that was still waiting for Health Canada approval. By the time it came to market I had different insurance.

Insurance authorizations and approvals

My most recent challenge with insurance was the battle of getting a combination of medications approved. I am sure that many of you have been through the circus that is dealing with insurance, their particular rules, formularies, and what feels like secret algorithms for approvals or denials. Until this point, I had just a few experiences with special authorizations and approvals. My experience involved the addition of a biologic. I was already on a specific biologic that I was receiving through a Patient Support Program (PSP) because it was recently approved and not yet on my insurance company's formulary.

Patient support programs (PSP) can be great, they help to arrange medication delivery, nursing support, all things insurance (there can be so many forms), they work with your physician/their practice to complete these forms and in a manner that favors approval. It is important to note that they want to help, however, they also want to receive reimbursement for their medication. In my experience, if they do not see a path to reimbursement, they can be a little less helpful or there may be specific limits (either financial or time) on their resources.

Overwriting previous approvals

Participation in these programs may also be a requirement for insurance approval/reimbursement. In my case, they are indeed not only a requirement but essential, they also tend to trip over their feet. In my circumstance, when I added another biologic, it ended up overwriting my previous approval and the insurer decided that I just needed to be on a single biologic. I did receive a call that I had been approved, however, I did not have an understanding that this would cause a chain reaction and I would lose coverage for the other medication.

This began an interesting adventure, relating to communication issues, appeals, advocacy to receive documentation and transparency in the medical review process. I am grateful that my specialist was patient with me, however, they were absolutely exasperated with the insurance company, which I understand is a typical response, because I know that I was at the end of my patience with this process. It looks like there will be more forms, and an additional authorization will be required because my insurance company made an independent decision. Navigating this progress can be exhausting and deflating, and in my opinion, is not for the weary.

How can the insurance process be easier for people with asthma?

I was once told that "three times the trick" with insurance. This has been my experience with anything complicated relating to insurance, however, may not be the case in all situations. This had me thinking about other diseases and conditions that have dedicated patient navigators. I know that many large medical centers have them, however, in a perfect world I would love to see more patient navigators for severe asthma. I understand that PSPs provide some of this support, however, I would have loved to have one for this process and even a patient cheerleader. There was only so much each party, including myself, could do. What are your ideas for making this process easier for patients?