Insurance coverage - Besremi

[PodKat]

Hi there - I am new to this forum, and find it super useful...

For my colleagues in the US - my insurance denied my prescription (twice!) for Besremi (and so instead, I am currently on Pegasys, which they do cover).

I'm curious if folks have had success with an insurance covering Besremi in the US for those of us that are not yet eligible for Medicare - health insurance is such a game here!

Thank you for any insight!

[hunter5582]

Even with a Medicare Part D plan, Besremi is not always covered. When it first came out, Besremi was not on my Medicare Part D formulary which is managed by Cigna. My doctor was not able to get it approved, so I had to mount my own appeal. I was ultimately successful.

In order to mount an appeal with any insurance plan, you need to understand how the plan rules work. Each plan has its own rules. Different plans from the same insurance company can have different rules. The first step in mounting an appeal is to get a copy of the plan rules for your specific plan.

Many plans these days have tiers for approval of medications that are on the formulary. Not all drugs are on the formulary for your plan. There are rules that govern access to higher-tier drugs and non-formulary drugs. Accessing these medications successfully requires and understanding of how this process works.

The first step in your situation is to check and see if Besremi is on your formulary. This determines the next steps to take. You will also need to find out why the request for Besremi was denied. How you appeal a formulary vs non-formulary denial is potentially different. You also need to find out about the levels and types of appeals that can be filed on your plan.

It is common with expensive medications like Besremi to get an initial denial. The next step in the process is often a peer-to-peer review, where the doctor calls the insurance company. It is still common to get a denial at this point. This is usually not the end of the process. There are still higher levels of appeal. Do not expect the insurance company to automatically provide this information. You may have to dig to get the information you need.

Being on Medicare Part D does not necessarily improve access to medication. My old pre-Medicare formulary had better access to medications than what I have now on Medicare. The key with any insurance plan is to understand how the plan works. There are ways to get things approved when they have been denied. You have to know how and be very persistent.

Many people find dealing with the insurance companies very difficult, if not impossible. It is possible to hire a patient advocate to help manage these issues if you wish. Here are a few links to patient advocates if you are interested.

nahac.com/

aphadvocates.org/

There is also assistance from PharmEssentia. You an find that at this link.

besremi.com/pharmaessentia-...

Wishing you success.

[EPguy]

The experience seems to depend on details of our insurance coverage. I have Anthem Blue Cross PPO pre medicare and had no trouble. An HMO could take more effort. But as Hunter says, it can be done with persistence.