Immune Globulin Therapy

1
Immune Globulin Therapy

• Navigating Insurance Coverage for Autoimmune
  Disorders

2
Summary of Topics

• Common Questions and Concerns
• Your Costs
• Medicare It is not free health care
• Denials and Appeals

3
Common Questions and Concerns

• How do I choose the right coverage?
• When can I change my coverage?
• Is my therapy covered?
• What are all these letters about (HMO, PPO, POS,
  IPA, TPA, etc)?
• What are consumer-driven health plans

4
Is IVIG Covered

• FDA Approved Indications for use of IVIG
• Primary immune deficiency disease (PIDD)
• B cell lymphocyte leukemia
• Acute idiopathic thrombocytopenia
• Bone marrow transplant (BMT)
• Pediatric AIDS
• Kawasaki disease
• Insurance Med-Policy
• Self-funded plans

5
The Acronyms

• HMOs
• An organization of healthcare personnel and
  facilities that provides a comprehensive range of
  health services to an enrolled population for a
  fixed sum of money paid in advance for a specific
  period of time.
• Restrictive movement to specialists
• Restricted provider network
• More hoops
• Less cost

Your rights under the types of plans
6
The Acronyms

• PPOs
• A group of physicians, hospitals, pharmacies and
  other providers contracted with employers to
  provide services. Contracted services are
  provided on contracted fee arrangement.
• Typically include out of network benefits
• Provide greater flexibility in specialist care
• Cost can vary by provider unlike stabilized costs
  in HMOs
• Higher out of pocket expenses than HMO plans

7
The Acronyms

• POSs
• Point of Service plans are essentially HMO plans
  with the benefit of out of network provider
  access.
• Because of the hybrid nature these plans fall
  between HMO and PPO plans with regard to provider
  access and cost

8
Be Careful!

• It is not that cut and dry
• Is your plan self funded
• Is your plan connected to a reinsurer
• Is there a pharmacy benefit and how does that
  change your coverage/decisions
• Beware of marketing speak
• Open Access Plan
• Blue Choice Plan
• Access to providers
• Any willing provider states
• Self funded plans
• You are your best advocate, but you must build a
  TEAM

9
Your Costs

• Copayments Paid each time you receive a service
• Deductible The total amount you must pay before
  your insurance begins paying
• Out of pocket maximums
• Pharmacy benefit capitations something new!
• Lifetime maximums

10
Medicare

• Can play a major role in your access to providers
  of all kinds
• Comes with significant personal costs
• You must inform your providers of any change of
  insurance this includes Medicare

Open Access Plan Blue Choice Plan
11
Denials and Appeals

• Avoiding claim denial
• Understand your policy
• Know your costs
• Know your policy authorization requirements
• Are you working with a reputable company with the
  experience to submit your claims properly

12
Denials and Appeals

• Prior-Authorization Process
• Coverage approval for IVIG is often dependant on
  the physicians demonstration of medical
  necessity
• Requests for coverage should always include
• Cover letter outlining request
• Brief overview of the disease pathology
• Brief overview of pt history and current clinical
  status
• Care plan
• Justification for treatment
• Current copies of clinical evidence supporting
  safety and efficacy
• Anticipated outcomes
• Costs

13
The Appeal Process

• Perseverance is key!
• Setting the stage
• Gathering preliminary information
• Work with your provider
• EOB analysis
• Writing the appeal letter
• State Insurance Commissioners
• State government
• Compelling cases

14
Insurance Challenges