FAQ (Frequently Asked Questions)


Getting Insurance | Insurance Denials | Copay Accumulator Program



Getting Insurance

  • How do I choose a plan based on a pre-existing diagnosis?
    • If you purchase a plan through the individual family plan market then you will not have to worry about pre-existing conditions as the Affordable Care Act has made all plans in the individual family guaranteed.
    • However, if you are purchasing an individual or small group plan outside of the Exchange, or enrolling in a plan through their employer it is important to check the plan documents, such as the Summary of Benefits and Coverage (SBC) or the Evidence of Coverage (EOCT) to see what may or may not be covered. Off-Exchange plans and some employer based plans are not required to follow the Affordable Care Act laws.
  • What do I do about insurance if travelling internationally or studying abroad??
    • Make sure to discuss with your provider where you will be traveling to be certain that your vaccinations are up to date.
    • Plan ahead! It may be possible to receive infused medications when traveling abroad. It can be country dependent but sometimes you may be able to work with the pharmaceutical company to arrange and it is often time-intensive to set up.
  • I’m changing my insurance plan this year. What should I do next?
    • Review the details of your new insurance plan to make sure your medications will be adequately covered and medical services you require (e.g. physical therapy, mental health care) will be covered under the new plan.
    • You should notify your physician’s office because new insurances typically require a re-authorization of biologic medications even if you have been on it long-term. If this re-authorization is not done in a timely way, this can result in missed doses.
  • What should I do if I have a gap or lapse in insurance?

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Insurance Denials

  • What should I do if I receive a denial from my insurance company?
    • First, look closely at the denial letter to determine why this service/drug was denied. It may be as simple as providing an appeal letter or submitting additional medical history to support the need for the service requested.
    • You can appeal the denial by following instructions from your insurance company – and include letters from your physician indicating medical necessity as well as a personal statement. Be sure to include policy number, claim number, date of service and complete contact info (home address, phone, email).
    • If the appeal is denied, inquire about applying for a pharmacy exception. This must be filed by your physician.
    • You can also reach out to your state’s Consumer Assistance Program (CAP) or Dept of Insurance: https://www.healthcare.gov/appeal-insurance-company-decision/external-review/
    • Another option is to reach out to Jennifer Jaff Careline for case management support and patient advocacy services: 1 (844) 244-1312 or email Jennifer Jaff

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Copay Accumulator Program

  • What should I do if I think I may have a copay accumulator program?
    • First connect with your insurer and ask questions – especially if you’ve been unable to fill your prescription. If you are employed and receive the insurance through your employer – tell them. They may have chosen this plan thinking it was a cost-savings strategy without understanding the negative impact it could have on employees.  Click here to learn more about copay accumulator programs.