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| MEDICAL: Treatments For PAH: Tracleer™ FAQ |
Frequently
Asked Questions
- Will most
HMO and PPO Insurance plans cover Tracleer™?
- Is Tracleer™ covered by Medicare/Medicaid or other
government insurance programs?
- Why wouldn't
Tracleer™ be covered by my insurance?
- If your
insurance will not pay, are there alternative payment options
for Tracleer™?
- What can
I do if my insurance company turns me down for Tracleer™ payment?
- What can
I do if I can't afford the co-pay for Tracleer™?
- Can you
detail the process by which "compassionate considerations" will
be developed for patients whose insurance has run out and who
are not eligible for public assistance on Tracleer™?
- What about
caps? When the insurance coverage is maxed out and the insurance
company refuses to pay, does the patient become eligible for compassionate
consideration at that point for Tracleer™?
- Will most HMO and PPO Insurance plans cover
Tracleer™?
Yes. To our knowledge all insurance companies are covering Tracleer™
for approved indications. However, that doesn't mean that your
specific pharmacy benefit will be adequate to cover your entire
cost of the medication. For example, Patient A and Patient B
are
both members of XYZ Insurance Co. Both patients receive essentially
the same medical coverage, but they have different pharmacy coverage.
Patient A has to pay only a flat "co-pay" of $50.00
every time a prescription is filled, regardless of how expensive
the medication, while Patient B has to pay 20% of the prescription
cost and the plan will pay the remaining 80%. With expensive
medications,
such as Tracleer™, Patient A has the better coverage. In this
example, Tracleer™ is covered for both patients, though it is
clear the
coverage amount varies depending on the plan you or your employer
are buying.
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- Is Tracleer™ covered by Medicare/Medicaid
or other government insurance programs?
Tracleer™ is covered by all state Medicaid programs. Most state
Medicaid programs may require the claim to go through a Prior
Authorization process. This process can lead to a slight delay,
but generally results in approval of the Tracleer™ claim. Medicare
does not currently cover oral drugs (with the exception of some
cancer compounds). Unfortunately, Tracleer™ is not covered on Medicare,
with no supplemental drug coverage. Medicare patients are encouraged
to contact T.A.P. (1-866-228-3546) should they need assistance.
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- Why wouldn't Tracleer™ be covered by my insurance?
Insurance coverage can vary from plan to plan. It is important
that you understand what type of insurance coverage you have and
be able to document why your plan may not be covering for Tracleer™.
A few of the more common reasons for no or delayed coverage may
be because a plan has not formally reviewed and determined coverage
criteria, the plans inexperience in the understanding of PAH,
or possibly certain exclusions of service in the plan. We encourage
you to contact T.A.P. with any insurance issues relating to Tracleer™.
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- If your insurance will not pay, are there
alternative payment options for Tracleer™?
To date we are unaware of any HMO or Medicaid providers that have
outright refused to pay for Tracleer™. Though some have been slow
to approve the claims and others may require a higher co-pay,
Tracleer™ is recognized as a reimbursable medication. Should you
experience non-insurance coverage for Tracleer™ we request that
you contact the T.A.P. program (1-866-228-3546). T.A.P. may be
able to assist you.
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- What can I do if my insurance company turns
me down for Tracleer™ payment?
The best advice we can give you is to get all the information
you can as to your coverage and the reason your insurance company
is turning you down. Again, for any assistance in this area we
encourage you to contact the T.A.P. program.
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- What can I do if I can't afford the co-pay
for Tracleer™?
Co-pays are a direct result of your insurance plan. Understand
what type of insurance you have and how your co-pay is calculated
(i.e. major medical versus pharmacy benefit). There are many reasons
why co-pays may be high. Once again, contact T.A.P. with as much
information as you can obtain and together T.A.P. and one of the
specialty distributors may be able to work with your insurance
plan and or at least understand your financial situation.
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- Can you detail the process by which "compassionate
considerations" will be developed for patients whose insurance
has run out and who are not eligible for public assistance on
Tracleer™?
It is difficult to detail any type of process since each situation
is unique and must be evaluated on a case-by-case basis. Patients
with the following situation are encouraged to contact T.A.P.
at 1-866-228-3546.
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- What about CAPS? When the insurance
coverage is maxed out and the insurance company refuses to pay,
does the patient become eligible for compassionate consideration
at that point for Tracleer™?
As stated above, these situations are reviewed on a case-by-case
basis. People with questions concerning CAPS should contact the
T.A.P. program with as much information on their specific plan
as possible.
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Actelion
Pharmeceuticals US. -- Used with permission.
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