This was a great website resource that one of the Eisai pharmaceutical reps shared with me (Eisai is the company promoting Belviq for Arena Pharm). The website it: www.eisaireimbursement.com
If your plan does not cover Belviq yet (I say yet because more and more are starting to cover), here are some options to try to get approved for individual coverage:
How to Request a Non-Formulary Coverage Determination
Health plans may grant various types of exceptions to members. Members may receive coverage for BELVIQ® even if it is not on the formulary, health plans may waive coverage restrictions or limits and make an exception to cover the drug.
When requesting an exception, a statement from their prescriber must be submitted via fax or mail. The statement must explain the medical reasons for requesting an exception. Once a request is submitted, a decision is generally made within 72 hours of receiving the prescriber's supporting statement. Members can request an expedited (fast) exception if the prescriber believes that a patient's health could be seriously harmed by waiting up to 72 hours for a decision.
- If the request is expedited and granted, the health plan usually gives a decision no later than 24 hours after receiving prescriber's supporting statement.
- If the decision is not in member's favor, the health plan will send a written statement with explanation and how to appeal the decision
- To download a general form that may be used to request coverage for BELVIQ® for a patient for a product that is not on formulary, please click here. Please note that some payors may not accept requests for coverage that are submitted on forms that have not been approved by their specific plan.
- If you need additional assistance obtaining a payor's specific requirements for requesting coverage for BELVIQ®, please call the Eisai Assistance Program at 1-866-61-EISAI or click here to obtain a Statement of Medical Necessity form. Once completed, please fax it to the Eisai Assistance Program. A representative will initiate research into the specific requirements of your patient's insurance to obtain coverage.
Appeal RequestAn appeal is a request to change a previous adverse decision made by health plan. A representative/prescriber or patient may appeal the adverse decision related to coverage. The prescriber will need to provide a reason why he/she believes the adverse coverage decision was incorrect and what the expected outcome should be. Along with the request form, supporting documentation may include previous medical necessity-related denials, the patient's medical records, and documentation from the healthcare professional or facility.
Payor ReimbursementCommercial payor pharmacy reimbursement for BELVIQ® is variable and dependent on the pharmacy's contract with the payor. Most commercial payors base payment on Average Wholesale Price (AWP) or Wholesale Acquisition Cost (WAC). Payments may or may not include a dispensing fee per fill.
For more information on commercial payor-specific coverage of BELVIQ® patients should contact the member services department at their health plan.
Patient Assistance Program
What is the Eisai Patient Assistance Program?Eisai has created the Eisai Patient Assistance Program (EPAP) for customers who need assistance paying for BELVIQ®. The Eisai PAP provides Eisai medicines at no or low cost to financially needy patients who meet program eligibility criteria.
About the ProgramDepending on your financial situation and clinical status, resources may be available to help with your costs for BELVIQ®. Patients, family members, advocates or case managers can call The Eisai Primary Care Assistance Program at 1-866-61-EISAI (1-866-61-34724) to apply to determine if you are eligible for the EPAP for BELVIQ®. The hours of operation are 8 AM to 8 PM ET, Monday through Friday.
Eisai reserves the right, at its sole discretion, to discontinue the Patient Assistance Program or change the qualifications at any time. All patient information remains confidential. Product supply for the program depends upon availability.
Information Needed For the ApplicationThe Statement of Medical Necessity, insurance information, financial documentation, the signature of the prescribing healthcare professional, and the patient's signature are required for the form to be considered complete. To download a copy of the BELVIQ® Statement of Medical Necessity Form, please click here. Fax the completed Statement of Medical Necessity to the Eisai Patient Assistance Program at 1-866-57-EISAI (1-866-57-34724).
Contact UsThe Eisai Assistance Program
Available Monday - Friday
8 AM to 8 PM ET