Everyone deserves to feel comfortable and confident in how to utilize his or her healthcare insurance benefits. And when your child is diagnosed with a rare condition like central precocious puberty (CPP), it’s extra important that you feel well-informed and equipped to know what’s covered by your insurance.
How do you gain that confidence while using Fensolvi treatments? We’ve outlined three simple tips to help you learn how to navigate central precocious puberty insurance and treatment coverage, appeals, and more.
Know the Details of Your Plan
First, you need a thorough understanding of certain details in your plan, including your deductible, out-of-pocket maximum, and in-network providers.
A deductible is the amount you pay out-of-pocket for medical care before your insurer starts to contribute their share for the medical claim expenses that you have incurred. Deductibles can work differently for families—your plan may include different deductible limits for every individual in your family, or your family may have one overall joint deductible. After you pay your deductible, you typically only need to pay coinsurance or a copayment for Fensolvi treatments.
Coinsurance is a percentage of the total cost of a healthcare service that you pay. For example, if your insurance plan has a coinsurance rate of 15%, you are responsible for paying 15% of the total cost of care. Meanwhile, a copayment is a fixed amount that you pay for a specific healthcare service or prescription. Your plan may require a copayment for each visit to your primary care provider and/or a copayment for refilling your prescription.
Out-of-pocket maximum is the dollar amount that represents the most money you need to pay for covered health care in an insurance plan year. This includes all money spent on coinsurance, copayments, and deductibles for in-network care. After reaching your maximum, your insurer will typically pay 100% of the costs of covered benefits.
Your in-network providers are medical professionals who accept your insurance plan. If a facility does not accept your insurance, they are an out-of-network provider. Check to see if your child’s pediatrician and pediatric endocrinologist are in-network or out-of-network to gain a clearer picture of total Fensolvi cost and payment expectations.
Familiarize Yourself With CPP Coverage and Appeals
Depending on whether you have commercial insurance or government-issued insurance (like Medicaid), Fensolvi treatment coverage can vary. Check your Certificate of Coverage (aka Pharmacy Policy or Coverage Policy) to know if Fensolvi is covered. Keep in mind that drug coverage can change throughout the year, so review your plan regularly to stay up-to-date.
Before your child begins Fensolvi treatment, your insurance provider may require prior authorization (PA): Documented evidence that your child needs the medication. How your doctor codes diagnoses and prescriptions can also impact your coverage, so work with your medical care team prior to starting treatment.
It’s also possible for your insurance provider to deny a prior authorization request, usually within a few days of receiving it. In this case, you can make an appeal. Most doctor’s offices will take care of appeals for you, but double check with your pediatrician’s office to make sure they’re advocating for your child’s selection of Fensolvi as their treatment of choice.
Once your child has authorization to receive treatment, his or her Fensolvi prescription will typically be filled by what’s known as a specialty pharmacy: A mail-order pharmacy that works with your doctor’s office to handle authorizations, fulfill orders, and ship your child’s medication to you or your doctor for administration.
Finally, know that Fensolvi offers payment assistance for treatment to offset costs. Fensolvi is happy to help with Fensolvi copay assistance, helping you pay as little as $5 for each 6 month dose.
Master Your Central Precocious Puberty Insurance Coverage
Now that you understand how Fensolvi insurance coverage works, here are the best practices on how to manage it:
- Attend your employer’s benefits open-enrollment meetings and ask questions.
- Check if your insurance provider offers extra services that can help you with treatment coverage, like a case manager, patient navigator, or rare disease manager.
- Don’t assume that your policy will stay the same: It will likely change from year to year!
- Open every piece of mail from your insurer and pharmacy benefits manager to make sure your child’s treatment is still covered.
- Keep a record of every interaction with your insurance company in case you need to make an appeal.
- Be your own best advocate! Remember, your insurance is meant to protect you—not overwhelm you—so don’t be afraid to ask questions and speak up on behalf of your family.
We do our best to ensure that you have the support you need and make navigating CPP simple for you and your child. If you have any additional questions regarding Fensolvi treatments, call us or visit our home page for more information.
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