Research helper for insurance gap?
March 9, 2022 12:05 PM   Subscribe

An acquaintance is starting an expensive drug that their insurance doesn't cover (even though it's FDA-approved and standard of care? This is confusing but it's apparently a pretty standard situation). They're looking for a "research helper" to explore charities and insurance possibilities that might help them bring the out of pocket cost down.

Does anyone have particular recommendations for how to find such a sort of a "patient advocate" but with research chops and domain knowledge? In the charity space and insurance space?

My acquaintance is low on spoons and is looking for this person to do legwork and create a list of things to apply for that fit their eligibility criteria. They are happy to pay a lot because it would potentially save a lot of money (or prevent accumulation of debt).
posted by zeek321 to Health & Fitness (6 answers total) 2 users marked this as a favorite
Best answer: Is there any chance they can get help from the prescriber or the pharmacy (probably a hospital pharmacy or other specialty pharmacy rather than CVS/Walgreens)? I have had insurance cover some fairly out-there prescriptions thanks to aggressive nurses and pharmacists who know how to deal with insurers.
posted by mskyle at 12:15 PM on March 9, 2022 [3 favorites]

Best answer: They should also contact their state AG or health insurance commissioner, as appropriate. Many states have some capacity to press insurers on coverage.
posted by praemunire at 12:18 PM on March 9, 2022

Best answer: The drug companies themselves often provide free or low-cost drugs to patients who can’t afford them. I'd suggest calling the manufacturer and asking about patient assistance.
posted by FencingGal at 12:48 PM on March 9, 2022 [4 favorites]

Best answer: This is incredibly common. The prescribing physician may have staff to help with this; more likely in a larger or academic/university practice than a solo or small private practice. For instance, I work with an incredible pharmacist and social worker who are wizards at finding drug coverage. Sometimes it's as simple as an appeal letter; might take a phone call. Otherwise, patient assistance programs are a good place to start. The PAN Foundation is another place to look.
posted by basalganglia at 1:41 PM on March 9, 2022 [1 favorite]

Best answer: I know this is a really dumb thing but I'm gonna mention it just in case: Has the physician's office been notified that insurance turned it down? Because sometimes it's just a *tiny* little change in the way the prescription is written that makes the difference. I had this happen with some dumb allergy medication, and as soon as I said "insurance rejected it" the doc was able to give me a new prescription -- same drug! -- that magically went through.
posted by BlahLaLa at 3:52 PM on March 9, 2022

My son and husband both take a very expensive med-Humira, which costs in the thousands per month. We are very fortunate to have excellent government employee health insurance, but if we didn’t, the drug company has a program to reduce costs or reimburse copays-I know they atent the only company with a high cost drug that does something similar:
posted by purenitrous at 7:37 AM on March 10, 2022

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