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- Tracleer® FAQ
- Under FDA Review
- 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.
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.
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™.
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.
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.
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.
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.
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.
Actelion Pharmeceuticals US. -- Used with permission.
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- March 17, 2011
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- February 17, 2011
- Actelion's Annual Report 2010