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Why Doesn’t HoG Take My Insurance?

By Michelle Fitzwater, Managed Care Contract Specialist

In the eight years I have worked for HoG one of the most common questions I have heard is “why doesn’t HoG take my insurance?”  It is a question that bothers me every time I hear it. HoG does not “take” or “not take” insurance.  If your insurance company will reimburse us for the medication we send to you, we will bill them. 

The problem is that every insurance plan is set up with specific rules that we cannot control.  Your employer (or you, if you have an individual plan) selects the particular insurance plan you have.  Even different plans within the same insurance company have different provisions for processing claims for factor products. Some plans let you choose any pharmacy you want to for your factor concentrate.  Other plans require that factor be dispensed by a specialty pharmacy that they choose.  

In order to find out if your insurance will pay for your factor if it comes from the HoG pharmacy, we have to check the requirements of your specific plan.  We work diligently to be in as many insurance company networks as possible so that we can serve everyone who wants to use the HoG pharmacy.  We also sign numerous contracts with drug benefit providers so we can be there for you when you have an insurance change.  Unfortunately we have not been able to cover them all yet but we will continue to try one contract at time.

Here’s an example of a recent success story.  The company John works for switched to a new insurance company that would not allow him to use the HoG pharmacy.  He had been with HoG for many years and wanted to continue to be able to pick up the phone and speak with Leigh at a moment’s notice or have his HoG nurse help him with any infusion problems.  He decided to have a discussion with his HR director to tell her about HoG and, most importantly, that we might be able to save the company money. He told her about HoG and all the benefits we provide to him.  He also asked the HR director to call me.  After I explained that using the HoG pharmacy would save John and his employer $2000 compared to the other insurance company, she agreed to allow John to use HoG.  We had to work through some details in the insurance company processing system but ultimately John was able to order from HoG again. 

If you want to use the HoG pharmacy but aren’t allowed by your current insurance plan, the first step is to meet with your employer. Usually employers are trying to save money for the entire company and do not realize how their choice within the benefit structure will affect you or your family.  You should request a meeting with the appropriate person in Human Resources and simply tell them your story.  Let them know you understand the costs of hemophilia and what you are doing to keep costs down, such as attending clinic at the HTC, and that using the Hemophilia of Georgia nonprofit pharmacy may be less expensive than other options.  This works best with self-funded plans, which are usually big companies that pay their employees’ medical bills themselves instead of going through an insurance company.  Once you’ve talked to your HR department, please put them in contact with me so I can show them the savings they may see by using HoG.

Another way is to negotiate an individual agreement with a case manager at the insurance company.  We have found that several insurance companies are willing to look at individuals instead of changing group plans.  This is a complicated and time consuming process but we have been successful in getting contracts at in-network benefit levels even if we are an out-of-network provider. 

Finally, we pursue contracts directly with the insurance companies.  Our goal is to become an in-network provider for your plan.  We have arranged meetings with companies like Blue Cross Blue Shield, Humana and Cigna to tell them our story.  We want to ensure we can continue to provide your factor products and keep your costs down.

We are not always successful.  There are times where companies are locked into agreements they cannot alter.  There are other times where there is a national level contract and the company is not willing to work with us.

If you cannot order from the HoG pharmacy and would like to explore developing an individual agreement or arranging a meeting with your employer, please contact me. I would be happy to explain how HoG may be able to save money for you, your employer and your insurance company.