New Medicines, New Process

Some prescriptions may be filled through your
pharmacy. Other medicines for cholesterol or heart
conditions have a different process that often has
several steps before you can take the medicine.

Some examples are:

  • Heart failure: Entresto®, Corlanor®, Jardiance®
  • Heart disease or very high LDL “bad,” cholesterol: Repatha®, Praluent®, Nexletol®, Nexlizet®, Vascepa®
  • Extremely high LDL due to familial hypercholesterolemia: Evkeeza™
  • High triglycerides: Vascepa®
  • Atrial fibrillation: Xarelto®, Eliquis®, Pradaxa®, Savaysa®
  • ATTR-CM: Vyndamax®, Vyndaqel®

Steps to Get the Medicines You Need

You and your healthcare provider will decide together what treatment will work best for you.

Step 1: Paperwork, Known as Prior Authorization

Prior Authorization, or PA, is sent to the insurance company to show that you
need the medicine. It is filled out by your health care provider, you, or a
family member.

You can help by providing copies or access to:

  • All your medical records
  • A list of your current healthcare providers
  • A list of providers you’ve had in the past

A Prior Authorization may include:

  • A detailed list of your previous medicines used to treat your condition and how they worked for you, such as:
    1. Name of medicine
    2. Medicine dose: how much you took each time
    3. Dates you used the medicine
    4. Any side effects you had
  • Your personal history of cardiovascular disease and sometimes a list of other family members who have cardiovascular disease, high cholesterol, ATTR-CM, or other risk factors.
  • Tests and procedures you have had. This information may be from other providers you have seen.
    1. Blood tests
    2. Echocardiograms
    3. Electrocardiograms, also called ECG or EKG
    4. Other tests or procedures, such as genetic tests
  • The reason your healthcare provider thinks this medicine will help you.

Step 2: Your Insurance Company Reviews the Paperwork

Your insurance company may take several weeks to review your paperwork. If more information is needed, you may work with your healthcare provider to gather and share information.

It may be common for the request to be denied, sometimes more than once. There is a process to appeal this decision, which means you and your healthcare provider can work together to share more information about why you need the medicine.

For more information on this process:

  • FH Foundation: Navigating Insurance Guide (PDF)
  • Patient Advocate Foundation: A Patient’s Guide to Navigating the Insurance
    Appeals Process (PDF)

Step 3: Getting Your Medicine

When the prescription is approved, it may be available only through a mail order or specialty pharmacy instead of the one you usually use.

  • Your medicine may be available at your local pharmacy or delivered by mail or delivery service. You may need to accept the delivery in person.
  • Your medicine may need special handling. Many injectable medicines must be kept at a special temperature while being shipped and require refrigeration after you get them.

Cost Considerations

Even though a medicine is approved by your insurance company, you will have to pay your portion. In most cases, you can figure out your cost at any time in this process.

Paying for Your Medicines

Even though your insurance company approves a medicine, you must pay your portion. In most cases, you can figure out your cost at any time in this process.

You may have insurance through:

  • Your employer
  • Your state
  • Medicare, Medicaid, or a government program
  • Tri-Care
  • The Veteran’s Administration (VA)
  • A different company that you pay directly

The cost of the medicine will depend upon what type of insurance you have. Talk with your insurance provider or benefits manager if you don’t know what co-pays or deductibles may be included in your plan.

Ask your provider if you need help finding whom to contact.

If the Cost is Too High, There May Be Help Available

When you get to the pharmacy, don’t pay for it if it seems too costly. Once you pay for the medicine and you leave the pharmacy, it cannot be returned. Call your provider to let them know.

If the cost of your medicine is too high, there may be help available. Your nurse or doctor can help you find the information you need.

Sometimes you can call your insurance company directly regarding the cost. Depending upon which type of insurance you have, you may be able to use one or more of the following resources:

  • Co-pay cards through the pharmaceutical company
  • Samples that may be available through your healthcare provider
  • Patient advocacy organizations

If you have Medicare, Medicaid, or Tri-Care, you may not be able to use co-pay cards and other assistance programs offered by pharmaceutical companies.

You Are Part of the Team

You can see there are many steps for many medicines. You and your provider will decide if this effort makes sense for you. You will then work together on the process.

A Partnership with Your Healthcare Providers

You can see there are many steps for many medicines. You and your provider will decide if this effort makes sense for you. You will then work together on the process.

Make Sure To Ask Questions Until You Understand Everything

Because the process of getting some medicines can take a long time, it is important that you think about whether you want to take the time and effort to get the medicines you need.

  • This is also a good time to think about whether you are willing and able to pay for your portion of the cost.
  • Some medicines may come as an injection. Make sure to talk with your nurse or doctor about how this medicine works, and decide if you are willing and able to take an injectable medicine.
  • It will be important for you and your healthcare team to communicate well with each other.
  • Everyone should keep track of who they have talked to, any results, and what still needs to happen.

Taking Your Medicines as They Are Prescribed

As a part of the team, it will be important for you to take your medicines as they are prescribed. Make sure you understand:

  • What medicines you are taking
  • Why you are taking them
  • How much you should take
  • Any side effects you might have

The medicines can’t help you if you don’t take them.

  • If ordered while in the hospital, before you leave, make sure to have enough medicine to last until your first visit with your regular provider.
  • Plan ahead for refills so you don’t run out. If you have travel plans, take enough medicine with you.

Even if it is working, you may not feel any different when you take your medicine, so it may not seem like it is working. Do not stop taking your medicine, or change how much you take. Talk with your nurse or doctor.

An important note: Sometimes, you will need to turn in new paperwork at the beginning of each year, even if your insurance stays the same. If your insurance changes, you may need to complete the process again.

You Have the Power

As a patient, you have power when it comes to talking about your insurance coverage. You may have more impact than your health care team.

Other Steps You Can Take

As a patient, you have power regarding your insurance coverage. You may have more impact than your healthcare team. If you are not satisfied, here are some steps you may take:

Check Your Insurance Coverage

Before you start or change medicines, see a new health care provider, or start or change insurance coverage, you can check to see what is covered and what it may cost. You can check the insurance company's website or call them with your questions.

You may need to complete another set of PA forms for the new company.

If there is a denial, call the insurance company. It can make a difference in the
PA process. You can also make sure you understand what is covered and what is not, as well as any additional information needed.

Talk With the Benefits Manager Where You Work

If your medicine is not covered, for example, you will want to let them know so they have the information when looking at insurance options for the future.

Contact the Office of Your State Insurance Commissioner

Patient calls are handled differently than calls from health care providers. There is also a time limit on the response time from the office. You can make a difference by letting others know about any problems you have in getting access to the medicines you need. You may be helping others in similar situations, too.

Disclaimer: While PCNA strives to provide reliable, up-to-date health information, this and other PCNA education materials are for informational purposes only and not intended as a substitute for professional medical care. Only your healthcare provider can diagnose and treat a medical problem.