Coverage.
The paperwork is the reason therapy stalls
Complex therapy rarely fails for clinical reasons. It fails because a prior authorization nobody chased expired, or a benefit nobody checked turned out to sit under a different part of the plan. We treat that work as the service, not as an afterthought to dispensing.
What we take on.
The coverage work, in full
Median referral to delivery
Median two days from the referral reaching us to the medication being delivered.
Repeat referrers
98% of our volume comes from practices that have referred to us before.
Inventory you carry
No inventory and no cash risk for your practice. You do not buy the drug or absorb a denial.
A pharmacist answers
A pharmacist answers the phone, not a call centre. Owner-operated, a live person every time.
Benefits investigation
We contact the plan and establish what is actually true for this patient: whether the therapy falls under the medical or the pharmacy benefit, what the cost share is, whether a deductible is in play, and whether the plan imposes a site-of-care requirement that changes where treatment can happen.
Prior authorization
We assemble the submission against the plan's own criteria, send it, and follow it to a decision. Where the plan wants something only the prescriber can supply, we ask once and say precisely what is being asked for.
Appeals
A denial is not the end of the referral. We work the appeal with the prescribing office, including peer-to-peer where the plan offers one.
Step therapy and documentation
Many plans require a documented history of prior therapies before they will approve. We work out what the plan wants to see and assemble it, rather than submitting and waiting to be told.
Renewals and re-verification
Authorizations expire and plans change at the start of a year. We track renewal dates against the dosing schedule and re-verify benefits at plan year changes, so coverage does not lapse quietly between doses.
In network
We are in network with the major Part D, Medicare Advantage and commercial plans. Which of them covers a given therapy, and under which benefit, is what the investigation establishes — but the contract is already there.
Financial assistance
Where a manufacturer or foundation assistance program exists for a therapy, we tell the patient about it and help them apply. We cannot promise anybody qualifies — but nobody should miss a program because no one mentioned it.
For the office.
What your staff stops doing
Your staff does not call the plan, does not sit on hold, does not build the submission, and does not track the expiry date. We ask your office for clinical information once, in a single request that says what the payer is asking for and why.
When you want a status, you call one number and get an actual answer from somebody who knows the case — not a promise that somebody will look into it.
Send records by fax, not email. Fax clinical documentation to (346) 350-6100. Ordinary email and web forms are not secure channels for patient information, and we will not ask you to use one.
For the patient.
What it means for you
You do not have to call your insurance company. You do not have to work out whether your therapy is covered under your medical plan or your pharmacy plan. You do not have to know what step therapy is.
We check it, we tell you what your share will be before anything is dispensed, and we tell you about any assistance program that exists for your therapy. If your plan says no, we work the appeal with your doctor’s office.
What to expect as a patientQuestions we get.
Coverage FAQ
Does my office have to submit the prior authorization?
No. We assemble it, submit it and follow it. We come back to the prescribing office only when the plan asks for something only the prescriber can provide, and we say exactly what that is.
What happens if the plan denies the request?
We work the appeal with the prescribing office, including a peer-to-peer review where the plan offers one. A denial is a step in the process, not the end of the referral.
Will you tell the patient what it costs?
Yes, before anything is dispensed. Once we have the benefit back from the plan we tell the patient what their share is. Nobody receives a medication from us and then discovers the cost.
How long does a prior authorization take?
That is the payer's timeline, not ours, and it varies by plan and by therapy. We will not give you a number we cannot stand behind. What we will do is tell you where the request actually stands whenever you call.
My patient's insurance changed. What now?
Tell us as soon as you know. Coverage has to be re-verified and an existing authorization usually has to be redone under the new plan. Starting that early is the difference between a smooth transition and a gap in therapy.
Let us take the payer off your desk.
Benefits investigation, prior authorization, appeals and renewals — worked by a team that does this all day and reports back in plain terms.