With the insurance payer landscape changing every day, one important demographic facing the backlash of these changes are cancer patients. Cancer research has resulted in expanding treatment options and rapid approval of many high-cost cancer drugs. However, insurance companies have struggled to update their medical policies and keep up in their provision of adequate coverage and access to care.
One particular drug class that has received a lot of recent attention is immunotherapy. Immunotherapy is a class of drugs that works with the immune system to fight off the cancer cells. If a doctor discusses the potential use of immunotherapy, these drugs can be fairly costly, and it is important for patients to know about their insurance requirements in advance. Typically the provider's office initiates the process of obtaining a prior authorization for approval of treatment from a patient’s insurance plan, so it is beneficial for patients to understand those requirements as well, and not be surprised. It is also important for patients to be aware of other coverage options if the insurance company denies the prior authorization or pre-determination.
Some examples of why something would deny could be based on:
● Lack of following step therapy requirements
● Missing biomarker testing
● Off label use
Off label means that a particular drug doesn’t meet the FDA guidelines for treatment. Specifically, in these scenarios, drug manufacturers may have programs in place to help provide copay assistance or treatment free of charge to the patient, or may be able to assist patients in obtaining additional third party funding if available.
For patients who have a commercial insurance plan, copay assistance may be granted for qualifying patients from the drug manufacturer. For patients with Medicare plans, third-party foundations may provide assistance for patients based on income or financial need. Some of these foundations and resources include:
● Healthwell Foundation, Patient Advocate Foundation
● Patient Access Network (PAN) Foundation
● The Assistance Fund
The programs provide copay assistance based on a specific diagnosis, for example, prostate cancer, and criteria for approval are generally based on patient income with a focus on helping patients most in need of financial assistance. Foundation support funds open and close frequently, so it is important to be patient if a specific diagnosis is closed at the time a patient’s doctor prescribes treatment, as it may very well open up within the week.
Drug assistance/patient assistance is another option open to all insurance types and each manufacturer has a set of their own eligibility criteria, but another great option to look into if patients are having trouble getting insurance approval or affordability issues.
Lastly, if the provider's office has a Financial Advocate it is a good idea to connect with that individual or team. Financial advocates hold a wealth of knowledge and may know the specifics for each drug, each drug manufacturer, and can help fill out the paperwork and move the process along quickly.
Some Helpful Resources:
*Please note that this information is not affiliated with Swedish Cancer Institute