PHA Pathlight Spring 2014 - (Page 15)
avigating the Affordable Care Act (ACA) and
understanding how it applies to your pulmonary
hypertension medications and insurance is critical.
What follows are some tips to help you be proactive
about changes in your insurance drug plans and to know
where and who to call with questions.
I. Know Your rIghts under the ACA
How will the ACA affect me or my PH caregiver?
The ACA does not fully address all of the concerns of
the PH community. However, many of the ACA's provisions
align with PHA's long-standing advocacy initiatives to
improve the quality of care for PH patients. The ACA
includes provisions that:
* Eliminate lifetime limits on essential medical
* Prohibit insurers from dropping your coverage
or raising your premiums if you get sick - or
from denying coverage if you have a pre-existing
* Ensure that your child can stay on your health plan
until age 26;
* Cap annual out-of-pocket medical and drug
expenses at an estimated $6,400 for individuals
and $12,800 for families;
* Establish high-risk pools for people with pre-
existing conditions who have been uninsured for
at least six months;
* Eliminate pre-existing condition exclusions for
people 19 years of age and younger;
* Require insurance coverage of routine patient care
costs associated with clinical trials;
* Gradually phase-out the Medicare Part D
(prescription drug) "donut hole" (began in 2010
and completely phases out in 2020).
For plan years beginning on or after Sept. 23, 2010,
the ACA prohibits most plans from imposing pre-existing
conditions limits on covered persons under age 19. For
plan years beginning on or after Jan. 1, 2014, the ACA
prohibits most plans from imposing pre-existing condition
limits on covered persons of any age. It is important
to fill out all forms completely and without mistakes.
Misrepresentations of material facts can call your
insurance coverage into question.
II. use Your speCIAltY phArmACY As A resourCe
Where to turn if you are experiencing a temporary
disruption in your insurance coverage:
Contact your specialty pharmacy to ask about
bridging services. Specialty pharmacies have programs
set up to help patients who are experiencing a temporary
disruption in insurance coverage with a transitional or
"bridge" supply of medication to support their continuity of
care. A bridge supply is a prescription of 15 or 30 days.
Call your care team as soon as you know of any
changes to your insurance. They will check your new
benefits to find how much of your drug will be covered.
Many insurance companies need to give their permission
ahead of time, and this can take as long as 30 days. Be
sure to let your care team know as soon as possible to
avoid a delay in getting your medication.
Ov ercom in g B ar rier s to G e t t i n g Yo u r P H M e d i ca t i o n s
III. use Your emploYer or Former emploYer As A
Your Human Resources (HR) Department will know
the details of your benefit plans. Before you change
plans, give your specialty pharmacy a call if you have any
questions. Ask whether your plan maintains a separate
list of specialty medications that are covered. Keep in
mind that the formularies are constantly in flux.
If you lose your job, you can sometimes keep your
policy with your employer for 18 months. You will have to
pay the insurance company to keep the coverage. This
benefit is provided through the Consolidated Omnibus
Budget Reconciliation Act (COBRA). You must get this
benefit within 60 days after you stop working. Another
option is to ask for coverage under a state program or
short-term medical insurance policy. Check with your HR
Department for additional details on these programs.
Go to www.phAssociation.org/Insurance to learn
more about the ACA, insurance and patient assistance
programs. For contact numbers for your specific
medications, see the "Insurance Resources" section on
the inside back cover of this issue of Pathlight.
You can provide feedback to your specialty
pharmacy by using PHA's Specialty Pharmacy
Feedback Form at www.phAssociation.org/
By Jennifer H. Keeley, ANP-BC, DNP, University of Pittsburgh
Medical Center Comprehensive Pulmonary Hypertension Clinic,
PATHLIGHT SPRING 2014
Patient-to-Patient Support Line: 1-800-748-7274
Table of Contents for the Digital Edition of PHA Pathlight Spring 2014
Coping with PH
Ask a PH Specialist
Advancing the Cause
PHA Pathlight Spring 2014