Payer Update, February 2023

Payer Update

Call the Alliance Bat Phone!
by Jeff Blake, Senior Vice President Member & Community Relations

At one of the breakout sessions at our Member Meeting in Nashville this month, we discussed various payer issues that our members encounter. The most common issue discussed was exclusive specialty drug carve outs to commercial specialty pharmacies, which prevent HTC pharmacies from dispensing to their patients. One person recommended the Hemophilia Alliance needs a “Bat Phone” to help HTCs with these urgent issues. After the meeting I reflected on this recommendation more and determined that we DO offer this “Bat Phone” service, but we need to remind and make our members more aware how we can help.

Recently one of our member HTCs contacted us with an urgent payer issue with one of their patients. For over 10 years the patient was receiving their medication from the HTC pharmacy. The HTC became aware of an insurance change when they were going to dispense to the patient in early January. The HTC was able to receive a 1-time override from the payer to dispense in January but they were told future dispensations would need to be filled by their exclusive specialty pharmacy. The HTC contacted us to see if we could help.

The HTC provided us with the necessary data to research and try to solve the issue – employer name (we determined this was a self-insured employer plan), medication prescribed, payer name and commercial specialty pharmacy. The Alliance Team immediately went to work utilizing our payer tools and resources. Within 48 hours we were able to determine the insurance broker that works with the employer on the health plan design. Within a few days we were able to meet with the insurance broker, highlight the clinical value of the HTC integrated medical and pharmacy care model and savings the HTC pharmacy would provide to the employer. In addition, we let the insurance broker know the patient wanted to continue to use the HTC pharmacy. The insurance broker met with their client to discuss our solution and their client agreed they should continue to allow the HTC pharmacy to provide services for the remainder of 2023 through an individual Letter of Agreement (LOA) with an option to renew the LOA for 2024. This was accomplished within 30 days. THERE IS NO CHARGE FOR THIS SERVICE BEYOND YOUR ANNUAL MEMBER DUES it is on top of your 27,749 % ROI.

Are you encountering payer issues that our “Bat Phone” service may be able to help? The Hemophilia Alliance Team is an email or phone call away to help. Feel free to contact me directly – or 317-657-5913 and I can connect you with the Director of Member and Community Relations for your center. Remember: we work for you!

Also in this Issue…

Notes from Joe
· Stepping Up Our Game

Alliance Update
· Update on Alliance Meetings for 2023!
· Pharmacist CE Conference 2023 Summary

Legal Update
· A New Era of Conundrums: Contracting with Related Pharmacies to Prepare for Gene Therapy

Washington Update
· HELP Copays Act Reintroduced

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