You might find these practical tips helpful when talking to your doctor about switching to new medications and obtaining coverage from your insurance company.
Be clear about whether your doctor is planning on adding a new medication to what you are already taking, or replacing one of your medications with the new one. Ask your doctor, “What medication will I be able to stop if I start the new one?” In general, if you are having a bad or inconvenient side effect from a medication, your doctor may want to stop that medication and start a different one. However, if your condition is not getting better, a new medication may be added to what you are already taking to try to improve your condition.
How is your doctor going to monitor your response to the new medication? Find out from your doctor what tests will be done to monitor your progress and how often each of them will be done. Keep a list of these tests and time periods and make sure that they get scheduled. Examples of some of the tests that might be used are a 6 minute walk test, echocardiogram, Right Heart Catheterization, and certain blood tests. If it has been more than 6 months since you have had any of these tests, remind your doctor about ordering them.
Report any and all side effects or problems to your doctor immediately. All of the medications for pulmonary hypertension are relatively new and in some cases little information is available to your doctor about possible side effects and problems when patients take different doses and untested combinations of medications for long periods of time. It is important for your health and for the physicians taking care of you to be alert for problems and side effects.
Investigate your insurance coverage. If you are not using a mail order pharmacy, call your insurance and see if mail-order is offered at a lower co-pay. Frequently, insurance companies have a program that will allow you to get a three month supply of a medication through the mail for much cheaper than the local pharmacy. For example, I recently had a patient starting Revatio. The local pharmacy was going to charge a co-pay of $200 per month. I asked the patient to call their insurance and they were able to obtain the same medication through a mail order pharmacy for $34 for a 3 month supply! Your local pharmacy will not give you this information.
Remind your doctor and nurse what pharmacy supplies your other medications for you. Your doctor may not realize what company supplies some of your other medications. It is easier for you to obtain all your medications from the same place and may speed up the process of getting them, since insurance authorization may take less time at a pharmacy that you are already established with. Also, tell your doctor and nurse if you are enrolled in a patient assistance program for a medication and receiving the medication for free.
Don’t take no for an answer from your insurance company. If your insurance company has denied coverage for a medication, appeal the decision and keep trying. You and your doctor should appeal the decision in writing and call your insurance company on a regular basis to check on the status. It is important to confirm that your insurance company has received your correspondence and to get the name and phone number of the person who is responsible for acting on it. Our office was very successful in getting Viagra (sildenafil) approved by many insurance companies prior to FDA approval of Revatio (sildenafil). In nearly every case, the request was denied on the first request and subsequently approved on the second, third, and sometimes fourth appeal.
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By Traci Housten-Harris, RN, MS, Johns Hopkins University. Additional medical review by Traci Stewart, RN, MSN, CHFN, Cardiomyopathy Treatment Program, University of Iowa.
To review Conflict of Interest Disclosures for PHA's medical leadership, visit: Disclosures
Last reviewed: February 2012