Tips for Accessing and Affording Specialty Medications

Some specialty medications are expensive or difficult to obtain. Be sure to use your insurance to cover as much of the cost as possible. Then consider other routes to affording your prescriptions.

Here are some common barriers to accessing specialty medications.

• Health insurance may require prior authorization before covering a specialty medication. This can be a lengthy process, requiring very specific coordination among the insurer, the prescriber, and the pharmacy.
• Health insurance plans are written in language that may be difficult to understand. Ask for clarification of terms that seem confusing.
• Many specialty medications are considered limited distribution drugs (LDDs). This means that they are often not stocked at pharmacies, unlike the more commonly prescribed medications. If your prescribed medication is an LDD, it may not be available in a timely manner or at all where your local pharmacy is located.

There are potential solutions to these barriers.

• An appeals process is available from your insurance plan. If your initial prior authorization is denied by the insurer, your healthcare provider can submit an appeal. They will need to describe in more detail the reason for that particular prescription. They will also have to explain why the medication the insurer recommends is not appropriate for your case.
• A specialty pharmacy may offer mail-order services for difficult-to-find medications, and can help you find financial assistance or suggest lower-cost alternatives. They will keep track of all the require paperwork, including annual changes in Evidence of Coverage (EOC).
• Patient advocates can do the background research needed to create a successful appeal of a denial. They can also help you get a second opinion, locate financial assistance, or apply for disability. They may be available through clinics, health plans, or peer support organizations.
• Financial assistance may be available when, even with approved insurance coverage, copays are unaffordable. 
• Manufacturer copay cards are often available for medications for which there is no generic version. 
• Manufacturer patient assistance programs may offer low-income persons free products.

Nonprofit foundations may have grants to help offset high prescriptions costs for patients on Medicare who have high copays. Some of these foundations are:

• The Assistance Fund
• Good Days Fund
• Healthwell Foundation
• Patient Access Network
• Patient Advocate Foundation

Nobody should have to go without necessary medication due to inability to pay.