Where is Your Factor Covered?

Horizons in Hemophilia, Winter 2009

By Michelle Fitzwater, Managed Care Contract Specialist

As you probably know, factor products are unique in the world of insurance. Since they are an injectible drug they are handled differently by different insurance companies and different plans. The way your plan covers these products will be key to determining how it will affect your bottom line.

If factor is covered under the major medical benefits section of your insurance plan, it is typically subject to your deductible, out-of-pocket and lifetime maximum costs. The benefit of having coverage under the medical plan is that you know how much your factor will cost from the start. Example: If your deductible is $500 and your out-of-pocket maximum is $1000, you know you will pay $1500 for your factor. If you have a flexible spending plan available, you can set aside money to pay this cost. If your plan does have a lifetime maximum, however, this may not work to your advantage. Once you use up the amount in the lifetime maximum you will no longer be eligible for coverage through the plan. Check to see if your plan has a lifetime maximum and what that amount is so that you can track it.

If factor is covered under the drug card part of your plan, you may have less out-of-pocket cost. Often you simply have a co-pay for every order. Your costs will vary depending on how often you need to order. There are some cards that will have a maximum, but thankfully these are still rare. The downside of drug card coverage is that you typically have less choice in providers and it is difficult to determine what you are actually paying for your factor. Often your drug card provider owns the specialty pharmacy that will send your medication. If you are unhappy with that service, there is often no other provider that is allowed to send medication.

Hemophilia of Georgia is here to help you navigate your benefits. Our dedicated Accounts Receivable staff will verify your benefits and discuss any co-pays with you; all you need to do is call. If you want to know if you can order from the HoG pharmacy, fax a copy of your insurance card, name and contact number to Sherry Turner, HoG’s Director of Accounts Receivable.