4 'Must-Dos' of Navigating Insurance

Health insurance can be confusing; it’s trickier for people on specialty therapies.

Woman in front of a laptop computer expressing frustration.

Along with having more than 25 years of experience in the specialty biopharmaceuticals industry, Kris McFalls has raised two boys who are living with a rare disease. Kris, a member of CSL Behring’s Reimbursement team in the U.S., regularly talks to other parents of children who require specialty therapies as well as patients themselves. She provides them with advice on navigating what can be a complicated topic – health insurance.Here are her four tips:

1) Be sure you’re talking to the right person.

If the person you are talking to isn’t helping to resolve your issue, don’t be afraid to ask to speak to someone else. For people on specialty therapies, the person who answers the phone at the health insurance company is often not the best person to talk to. That’s because this person may just be looking at a process chart to answer questions, and for a person with a rare condition, that condition is probably not on the chart. Importantly, if someone tells you that your medication doesn’t require proper authorization, ask to speak to a supervisor, because specialty medications almost always require prior authorization.

2) Speak the right language.

Have you ever text messaged with friends and had a hard time understanding what they are saying, because of all the different acronyms they use? Trying to understand information from your health insurance company can feel the same way sometimes, because they use a lot of different codes. Make sure you have the necessary codes and know what these codes mean before talking to your insurance company, as you may be asked for these codes when discussing your medications.

Some important codes you should know in the U.S.  (Note: It’s important to always double-check with your provider or resources mentioned below to ensure the codes obtained are accurate based on the given disease and diagnosis):

J-Code – This code is part of a standardized coding system (HCPCS) used for medical billing purposes and describes the specific product you are using. When new medications are made available, they sometimes are assigned a miscellaneous code instead of their own specific J-code. This is why it’s important to make sure you talk to the right person about your medication if you’re told your medication will not require prior authorization.

NDC – The National Drug Code is a unique product identifier that consists of 10 or 11 digits with three segments generally found on your medication packaging. You can also obtain this number from the product manufacturer’s website or your infusion provider.

CPT Code – The Current Procedural Terminology code is a long number that describes the procedure for administering your therapy. Your infusion provider can give you this code.

HCPCS Code – The Healthcare Common Procedure Coding System (HCPCS) describes the supplies (including medicines) rendered by the billing provider.  These may include medical supplies used (for example an infusion pump and pump supplies used to inject your therapy). 

ICD-10 code – This is the code that describes your medical condition typically associated with your disease. You can get this code from your doctor. This is the 10th revision of the International Statistical Classification of Diseases and Related Health Problems, a medical classification list by the World Health Organization.

3) Keep good records.

Write down all of the above codes for your medications, along with recording the dosage and frequency for each therapy. Also be sure to keep logs of incidents such as serious bleeds if you have a bleeding disorder and any important changes to your health. You should provide this information to your doctor who will make it part of your medical record.

Save your receipts, and be aware that a tape register receipt is not enough evidence for a Health Savings Account or Flexible Spending Account claim. Your doctor can provide you with the correct receipts for these purposes.

4) Don’t be afraid to ask for help.

Reach out to people such as your pharmacist, your doctor and manufacturer reimbursement managers like Kris. Every condition, including rare diseases, has a community you can connect with either online and/or at events to learn from other people who have experienced what you are going through right now. For example, hemophilia treatment centers are an especially great resource for people with bleeding disorders.

If you’re seeking prescription assistance with your medications, the website www.needymeds.org is a great resource. Also be aware that you can visit a manufacturer’s website and find forms that you can complete to get additional assistance – you don’t need to ever pay any organization for this help.

Your pharmacy may have assistance programs, but you have to ask about them. Once you do, they’ll let you know about any programs they offer.

Companies like CSL Behring also offer online resources. All of CSL Behring’s assistance programs in the U.S. are highlighted here.

Remember, the answer to what you are asking for might not be “yes,” but if you don’t ask, it will definitely be “no.”

Note: This article is provided as general information only. Before relying on the material in this article please carefully evaluate your own insurance policy and circumstances and consider consulting with a paid professional. Links to specific websites and resources do not constitute endorsement.