Patient Resource Guide

Transcription

1 Access Services Patient Resource Guide AstraZeneca Access 360 is committed to helping you access our medicines. This guide will provide you with information and resources to help you understand how to access your medicines and complete your treatment plan. Learn about the AstraZeneca Access 360 program, commonly used insurance terms, different ways your medicines can be covered, and how to get your prescriptions. If you have any questions about this guide, or need guidance on what to do after your doctor has written your prescription, contact Access 360 to speak with a Reimbursement Counselor at Monday to Friday from 8 AM 8 PM EST. Introduction Getting Your Medicine Coverage Approvals Reimbursement

2 How to get started on your AstraZeneca medicines AstraZeneca Access 360 has staffed experienced and well-trained Reimbursement Counselors who can help you. Call us today at Monday Friday, 8 AM 8 PM EST. Access 360 can help you find, download, and complete any forms and paperwork needed to access your AstraZeneca medicines. Access 360 can also help you: Navigate Identify Introduction Navigate your insurance coverage plan and explain any details What are the different types of insurance coverage? There are several choices in the types of health care organizations that will pay for some or all of your health care expenses, including your medicines. Commercial carriers offer group and individual plans, provided for a regular monthly premium or fee, while there are state and federally funded insurance programs (Medicare, Medicaid, etc.) that you may be eligible for based on your situation. Connect Connect you to affordability programs Depending on your type of insurance, or if you do not have insurance, we can help identify what support programs you may be eligible for Medicare Overview Medicare is a federal health insurance program that mainly provides coverage for people who are over the age of 65, blind, or disabled. This program only pays for medical services and procedures that have been determined as reasonable and necessary. It is important to note that there are various parts of Medicare, and benefits vary based on the type of coverage you select. Medicare Part A Hospital Insurance: Covers inpatient hospital services and certain follow-up care. Medicare Part C Medicare Advantage: Also known as Medicare Advantage, covers Part A and Part B benefits and could also include prescription coverage. Medicaid Medicare Part B Medical Insurance: Covers physicians services and supplies not covered by Part A and requires a monthly fee set by the federal government. Medicare Part D Medicare Prescription Drug Coverage: These are private insurance plans specifically for prescription drug coverage. Medicaid is a health insurance assistance program for some low-income people (especially children and pregnant women) sponsored by federal and state governments. Coverage varies from state to state. If you are unsure of the type of coverage or plan you have, Access 360 can help. Call us at Monday Friday, 8 AM 8 PM EST. Patient Resource Guide Introduction 02 Introduction Getting Your Medicine Coverage Approvals Reimbursement

3 Introduction Getting Your Medicine Coverage Approvals Reimbursement Patient Resource Guide Getting Your Medicine 03 Getting Your Medicine I have a doctor s prescription what do I do next? Once your doctor prescribes your medication, it is typically filled by a pharmacy. It is important to note that most of the medicines supported by the Access 360 program are medicines that are filled through specialty pharmacies. Specialty Pharmacies Just like a retail pharmacy, these pharmacies carry and sell prescription medicines available to you or to your health care provider; however you receive them via mail. Specialty pharmacies typically handle medicines that treat specialty conditions. For example: Cancer Respiratory Syncytial Virus (RSV) Certain respiratory conditions Injectable medicines Biologic products Specialty medicines usually need to be stored under special conditions as required by the FDA. Specialty pharmacies are prepared to handle, store, and distribute such medications. Health insurance plans and doctors can advise patients if they need to get medications through a specialty pharmacy. These pharmacies may also provide additional counseling and support services, such as: Insurance/reimbursement assistance Medication review Managing and monitoring side effects Injection support Help staying on treatment How does Access 360 work with Specialty Pharmacies? Access 360 works closely with specialty pharmacies and your health care provider to ensure you get your AstraZeneca specialty medicine quickly. At your doctor s request, we will investigate your plan benefits to find out which specialty pharmacy works best with your health plan. We work with the specialty pharmacy to ensure we have the necessary paperwork from your doctor so that you can receive your medicine. What is the difference between Medical vs. Pharmacy benefits? Medical benefits refer to the type of coverage and reimbursement available to you through your medical coverage, whereas your pharmacy benefits are coverage and savings available to you for your prescription or medicine coverage. Typically, you will have two different cards for each coverage benefit and varying co-pay amounts for each benefit, including different approval requirements for each based on your plan. The costs of your medicines can be paid through your health plan s medical benefits or through the pharmacy side of the same plan. If you are unsure which benefit your prescription medication will be covered under, speak to your doctor. Access 360 can work with your doctor to conduct a Benefits Investigation to verify your coverage options and determine how your medication will be covered. We can also ensure your doctor has the proper insurance claims paperwork so they can obtain reimbursement if necessary. Patient Resource Guide Getting Your Medicine 04 Introduction Getting Your Medicine Coverage Approvals Reimbursement

4 Introduction Getting Your Medicine Coverage Approvals Reimbursement Patient Resource Guide Getting Your Medicine What are out-of-pocket costs? Out-of-pocket costs are expenses, usually co-pay, deductibles and co-insurance, that you ll be required to pay yourself based on the terms of your health insurance plan and its coverage of approved medicines and services. You need to understand what out-of-pocket costs you are responsible for before you receive any service or obtain your medicine from the pharmacy. Special discount programs may be available directly from AstraZeneca that can help cover some or all of your medicine costs. What is a deductible? A deductible is a preset percentage or predetermined amount that you may be responsible for paying before your health plan coverage picks up the remaining costs of medicines, devices and provider services. These amounts can be based on each visit or can be added up over the year. What is a co-pay? Co-pays, also known as co-payments, are fixed medical costs that you are responsible for paying for any medical service or for a prescription medicine. What is coinsurance? Coinsurance is the percentage of costs of a covered health care service you pay (20% for example) after you ve paid your deductible. What is a prior authorization? A prior authorization is a requirement that your physician obtain approval from your health insurance plan to prescribe a specific service or medicine for you. One of the support services provided by Access 360 includes identifying specific forms and submission requirements in order to provide you with step-by-step instructions on how to receive approval for your AstraZeneca medicine. What is a denial of coverage? A denial of coverage (DOC) is a notification from your insurer describing why your claim for coverage or reimbursement for a medication has not been approved. The DOC may be sent to you separately or included in your Explanation of Benefits (EOB a statement sent by your health insurance company explaining what medical treatments and/or services were paid on your behalf). You and your doctor can appeal a denial by following the process outlined in your denial letter. Coverage Approvals How to navigate the medicine coverage approval process Health insurance plans are very specific about what costs or services and medications they will cover. This usually includes the amount they will pay, the total amount of coverage per year and instruction on how you can receive your cost-savings benefits each time you see a doctor or get a prescription filled. Below are the typical steps of what to expect with the medicine coverage approval process: STEP 01 STEP 02 STEP 03 Health care provider appointment You visit the doctor for a specific condition or illness Treatment decision The doctor makes a diagnosis and prescribes a procedure or medicine Health care provider s office confirms coverage The office requests your medical insurance information to verify your benefits and coverage options or scheduling a procedure. The office will schedule an appointment for you for your treatment If you are having a procedure, your doctor will administer your treatment After your appointment, the doctor s office will submit a claim to your medical insurance company for payment or ask you to pay a pre-approved co-pay Patient Resource Guide Coverage Approvals Introduction Getting Your Medicine Coverage Approvals Reimbursement 05 06

5 Introduction Getting Your Medicine Coverage Approvals Reimbursement Patient Resource Guide Reimbursement Roadmap 1 Reimbursement Roadmap Depending on your provider and the treatment performed or medicine you were prescribed, you ll receive a reimbursement for the full or partial amount of your treatment. If your medicine is covered by your health plan a) The office will schedule an appointment with you for treatment b) Treatment Received c) Claim Submitted the office submits a claim to your medical insurance for payment d) Insurance processes your claim the claim is processed and the doctor s office receives payment for medicines and services rendered If you are covered but your plan has a co-pay or other shared expense a) The doctor s office will bill you for your out-of-pocket cost-share responsibility b) Treatment received the doctor examines you and discusses your health condition c) Claim submitted the office submits a claim to your medical insurance for payment d) Insurance processes claim your responsibility for any costs is confirmed. Your claim is processed and your doctor s office receives payment for medications and services. e) Office bills you for your out-of-pocket responsibility. This may include co-pay, deductible or a co-insurance payment. If your medications are NOT covered If you don t have medical insurance or a plan that covers prescriptions, you should talk to your doctor for cost-saving options that are available, including: Monthly payment plans Patient Protection and Affordable Care Act (PPACA) options, if eligible Charitable organizations You may also contact Access 360 to speak to a Reimbursement Counselor to learn about alternate support programs that you may be eligible for 3 Patient Resource Guide Reimbursement Roadmap Introduction Getting Your Medicine Coverage Approvals Reimbursement

6 Introduction Getting Your Medicine Coverage Approvals Reimbursement Patient Resource Guide What should I do if my claim is denied? Even when treatments are pre-approved for coverage, the claim can be denied by the insurance company. Who should I talk to if my appeal of coverage is denied? Access 360 can help you and your doctor navigate a denial. Our appeal support services include: An in-depth review and explanation of your denial notification Research in order to provide you with step-by-step instructions for all appeal options including with your insurer and state Templates to assist with the appeal letter-writing process and other documentation to build your case Patient Resource Guide Introduction Getting Your Medicine Coverage Approvals Reimbursement 09 An Access 360 Reimbursement Counselor can also follow up on an appeal submission until a decision is obtained. If your health plan is an employer self-funded plan, there are additional appeals processes available. Contact your employer s human resources department for more detailed information. 10

7 AstraZeneca Access 360 provides you with free personal support to help you so you can have access to the medicines you need. We will make every effort to work with you to help you navigate complicated financial and insurance questions. Our knowledgeable and compassionate Reimbursement Counselors will try to provide you with the support you need so you don t have to miss a dose. We can help you with: Complicated insurance questions and processes Locating a pharmacy Finding the financial help that is right for you Providing information about support programs that you may be eligible for if you don t have, or have been denied, insurance coverage Call today to meet your AstraZeneca Reimbursement Counselor at 844-ASK-A360 ( ) Monday - Friday 8 AM-8 PM ET. For additional information, visit Connecting with AstraZeneca Access 360 is easy. Contact us to learn more: 844-ASK-A360 ( ) 844-FAX-A360 ( ) Access360@AstraZeneca.com One MedImmune Way Gaithersburg, MD AstraZeneca Access 360 is a trademark of the AstraZeneca group of companies AstraZeneca. All rights reserved Last Updated 3/17