When coverage is not access: A heart transplant recipient's perspective on everolimus, U.S. Food and Drug Administration labeling, and the problem of "ghost approval".

Access to immunosuppressive therapy is essential for long-term survival in heart transplant recipients, yet insurance coverage does not always translate into meaningful access. This perspective introduces the concept of "ghost approval," in which a medication is technically approved but remains financially or logistically inaccessible to the patient. Drawing on a first-person experience with everolimus, an mechanistic target of rapamycin inhibitor without a U.S. Food and Drug Administration indication for heart transplantation, this article highlights the gap between regulatory labeling, clinical practice, and insurance coverage decisions. Despite documented medical necessity and clinical stability, coverage restrictions-including high specialty-tier placement and pharmacy limitations-created substantial barriers to obtaining therapy. This misalignment places patients at risk of treatment interruption and adverse outcomes. Greater alignment between regulatory frameworks, real-world clinical practice, and insurance policy is needed, along with stronger protections to ensure that coverage results in timely, reliable, and affordable access to life-sustaining medications.