Heart Transplant Recipient Describes Insurance Coverage That Does Not Provide Medication Access

A heart transplant recipient reports that insurance coverage for a prescribed anti-rejection drug did not result in actual access to the medication. The patient, Payton Herres, states that her transplant team prescribed everolimus, which is FDA-approved for liver and kidney transplants but used off-label for heart transplant patients.

She writes that the drug can help preserve kidney function and reduce the risk of cardiac allograft vasculopathy. On paper, the medication was covered. In practice, the insurer required multiple prior authorizations and peer-to-peer reviews before denying the prescription.

Herres states that she was days away from running out of medication and experienced sleepless nights and stress at work.

Herres posted on Facebook seeking help, and the post was shared more than 4,900 times. Her donor's mother offered to pay for the medication. Following the public attention, Anthem approved the prescription. The cost remains approximately $500 for a 30-day supply.

Herres states that she earns just over $35,000 per year and that mail-order delivery is not a safe option for transplant medication. She is currently receiving the drug through assistance from Claimable CEO Warris Bokhari and businessman Mark Cuban via the Mark Cuban Cost Plus Drug Company.

Herres states that similar access problems affect other patients even when coupons or savings programs are available. She uses the term "ghost approval" to describe coverage that exists on paper but does not provide reliable access to prescribed medication.