New Medicines, New Process
Some medicines require extra steps for you to receive them. This tool is designed to help you better understand the prior authorization process and your role in getting—and taking—innovative medicines.
Medicines that May Require Extra Steps
How Do I Get the Medicines I Need?
How Much Will My Medicine Cost?
Working with Your Provider as a Team
What Can I Do To Get the Medicines I Need?
Medicines That May Require Extra Steps
When filling a prescription, usually the pharmacy will receive a fax from your health care team, or you take a written prescription to the pharmacy. This tool will help you
understand the extra steps that may be needed for medicines such as these:
- Heart failure: Entresto®, Corlanor®, Jardiance®
- Very high LDL cholesterol and familial hypercholesterolemia: Repatha®, Praluent®, Leqvio®, Nexletol®, Nexlizet®
- Extremely high LDL due to familial hypercholesterolemia: Evkeeza™
- High triglycerides: Vascepa®
- Atrial fibrillation: Xarelto®, Eliquis®, Pradaxa®, Savaysa®
- ATTR-CM: Vyndamax®, Vyndaqel®, Attruby®, Amvuttra®
- Hypertrophic Cardiomyopathy: Camzyos®, Myqorzo®
- Pericarditis: Arcalyst®
How Do I Get the Medicines I Need?
You and your health care provider will decide which treatment is best for
you.
Your Healthcare Team Will Fill Out and Send a Form Called a Prior Authorization, or PA, Which will:
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- Describe why you need the medicine
- Include information about your health, past and current medicines, tests, and procedures
The Insurance Company Reviews and Responds
-
-
- You can ask the company when to expect a response
- The company may ask for more information
- Sometimes the request is denied. Call the insurance company for more details. You can appeal the decision by sending more information.
- For more information on the process, visit:
- FH Foundation: Navigating Insurance Guide
- Patient Advocate Foundation: A Patient’s Guide to Navigating the Insurance Appeals Process
-
When Approved, Fill the Prescription at a Pharmacy That Has the Medicine
The pharmacy will let you know if there is anything special about how to get or store your medicine.
Learn More
Explore these topics further to learn more about getting the medicines you need.
How Much Will My Medicine Cost?
Working with Your Provider as a Team
What Can I Do To Get the Medicines I Need?
How Much Will My Medicine Cost?
Even though a medicine is approved by your insurance company, you may have to pay a portion. In most cases, you can figure out your cost at any time in this process.
The Cost of Your Medicine
Even when a medicine is approved by your insurance company, you may have to pay a portion. The cost will depend upon the type of insurance you have.
Find out what your cost will be by talking with your insurance provider or benefits manager. They can let you know what co-pays or deductibles you have.
Ask your provider or pharmacist if you need help finding the right contact.
What if the Cost of My Medicine is Too High?
Don’t pay for a medicine if it seems too costly. Once you pay for the medicine, it cannot be returned. Call your provider to let them know you did not receive the medicine and why.
You May Be Able to Get Help Paying For Your Medicines
- Your nurse or doctor can help you find programs that can help you pay for your medicines, and the information you need to apply.
- With some insurance plans, you may use:
- Co-pay cards from the drug company
- Samples from your health care provider
- Patient advocacy organizations
Learn More
Explore these topics further to learn more about getting the medicines you need.
Medicines that May Require Extra Steps
How Do I Get the Medicines I Need?
Working with Your Provider as a Team
What Can I Do To Get the Medicines I Need?
Working as a Team
You and your provider decide if the work to get the medicine makes sense for you, or if there is another option.
Make Sure To Ask Questions Until You Understand Everything
- Decide if you can take the medicine. Some are given as an injection.
- Think about the time and effort it may take to get the medicines you need.
- It may seem like a challenge to get the medicine, but don’t give up.
- Decide if you can and are able to pay for the medicine.
You and Your Health Care Team Will Need to Keep Each Other Informed
Keep a copy of the information that you send and what you get back. You may need to resend information.
Keep a Record Of:
- Who you talked with
- What happened
- Next steps
Take your medicines as they are prescribed.
Make sure you know what to take, when and how to take it, and any side effects that you may expect. Plan ahead for refills so you don’t run out.
Don’t stop taking medicines without talking to your health care team.
You may not feel any different even when the medicine is working.
Learn More
Explore these topics further to learn more about getting the medicines you need.
Medicines that May Require Extra Steps
How Do I Get the Medicines I Need?
How Much Will My Medicine Cost?
What Can I Do To Get the Medicines I Need?
What Can I Do To Get the Medicines I Need?
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.
You Have The Power
As a patient, you have power when it comes to talking about insurance coverage. If you are not satisfied, you may:
Contact Your Insurance Coverage
- Check what is covered and what it may cost.
- Be sure to check before you start or change medicines, see a new provider, change pharmacies, or start or change insurance coverage.
- You may need to send a new set of PA forms.
Talk with the benefits manager where you work.
Tell them if your medicine is not covered, which may help when they are looking at future insurance options.
Contact Your State Insurance Commissioner
Sharing Your Experience May Help Others in Similar Situations
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.
Learn More
Explore these topics further to learn more about getting the medicines you need.
Medicines that May Require Extra Steps
How Do I Get the Medicines I Need?
How Much Will My Medicine Cost?
Working with Your Provider as a Team
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.
