Dear Ally, We just received a notice that our insurance will no longer cover my son’s preferred brand of clotting factor. They are asking us to switch to a different brand, but we’re concerned about how this might affect his treatment. What can we do?
~Kimberly
Dear Kimberly, Receiving a notice like this can be unsettling, especially when your child is stable on their current treatment. Here are some steps you can take to address this situation:
- Contact Your Healthcare Provider – Speak with your child’s hematologist or HTC Social Worker as soon as possible. They can assess whether switching to the new brand would be medically appropriate or if staying on the current brand is crucial for your child’s health. If the latter is true, your healthcare provider can help advocate for continued coverage.
- Request a Formulary Exception – Many insurance plans allow for a formulary exception, which means they may cover the preferred brand if your healthcare provider can show it’s medically necessary. This often requires a letter of medical necessity from your child’s doctor explaining why the current treatment is the best option and why switching could negatively impact their health.
- File an Appeal with Your Insurance Company – If the formulary exception request is denied, you can file an appeal. In this appeal, include documentation from your healthcare provider, any previous treatment history showing why the current brand is effective, and information on why switching brands could pose a risk.
- Explore Financial Assistance – If your insurance insists on not covering the current brand, consider reaching out to the manufacturer of your child’s clotting factor. Many pharmaceutical companies offer financial assistance programs that may help cover the difference if insurance doesn’t.
- Connect with Patient Advocacy – The Hemophilia Foundation of Maryland and other patient advocacy groups can provide resources and support when facing insurance challenges like this. We can help you navigate the appeal process, connect you with financial assistance options, and ensure your family receives the treatment your child needs.
*Switching brands can be a big change, but with the right steps, you may be able to continue using the current treatment or find a suitable alternative. We’re here to help every step of the way.
