And in the case of Epogen, Amgen will give patients who qualify subsidies, or sometimes even provide the drug at no cost. There are a variety of reasons why a patient may be refused coverage for a drug. These include ambiguity in the prescription for a medication that has multiple uses. A health plan may need clarification that the use is not a cosmetic one. In this case, the question of coverage can be resolved without a drug company's help.
Advocacy often comes into play when drugs are new or are being prescribed for new uses.
When a patient is refused coverage for a medication, the drug maker often will help in the appeals process by making phone calls to determine what a patient's policy will and will not cover, and by working with the doctor to write a letter of medical necessity. In the latter situation, the drug company may provide additional information about how a medication works and its effectiveness, including sending the physician journal articles to help support the appeal. Pharmacies at these clinics, which serve the working poor, do not have a ready supply of drugs to fill prescriptions immediately. The majority of the programs give a patient enough medication to last three months. To fill the gap, Smarinsky says the clinic relies on free samples that drug company representatives bring with them when they visit the clinic.