The following article was provided by the Association of
Community Cancer Centers. Please see our
Your Insurance Should Cover
Information for Patients and Their Families
The Association of Community Cancer Centers
The Oncology Nursing Society
The National Coalition for Cancer Survivorship
(c)1991 Association of Community Cancer Centers
Attempts To Control Health Care Costs Should Not Deny
Patients Access to Effective Cancer Treatments.
All Americans (the public, hospitals, doctors,
nurses, employers, and insurance companies) are concerned
about controlling health care costs.
Unfortunately, in the legitimate quest to control
health care costs, some insurance companies are denying
payment for new, effective cancer therapies. This brochure
provides important information for cancer patients and their
- Why insurance companies are denying payment for effective
- What can be done if payment is denied for your treatment
- How to ensure that your insurance plan provides adequate
coverage for cancer treatments
- How cancer patients and their families can help
Why Are Insurance Companies Denying Payment for Effective Cancer Treatments?
- Insurance Companies Are Not Aware of New Treatments.
Often insurance companies are not aware of new treatments
for cancer and, initially, they may refuse to pay for
them. As a result, doctors, hospitals, and cancer centers
must provide insurance companies' with information about the
effectiveness of these new treatments if payment is denied.
- Some Insurance Companies Limit the Selection of Drugs To
Control Costs. Insurance companies, in an attempt to control
their costs, may try to limit your doctor's selection of
therapies to those that are lower in cost. Such a policy
forces physicians and patients to accept older, less
adequate treatments in lieu of the most effective,
state-of-the-art treatments available. In fact, a recent
Gallup survey of physicians specializing in oncology showed
that 15 to 40 percent of their patients are denied the
treatment of choice by their insurance plans.
- Some Insurance Companies Are Restricting Payment to the
Uses Initially Approved by the FDA. The U.S. Food and Drug
Administration (FDA) performs an extensive review of all new
drugs to ensure that they are safe and effective before they
are released on the market. The uses for which a drug is
reviewed and approved are listed on the drug "label" or the
"package insert" developed by the FDA.
However, after the FDA's initial review, doctors and
scientists continue to find new, effective uses for approved
drugs in the treatment of a number of different types of
cancers that are not included on the FDA label. These new
uses are reviewed and listed in three major drug reference
books that have been recognized by the United States
Nevertheless, some insurance companies are
restricting payment to only those uses included on the
original FDA label. Strict adherence to such a policy could
result in denials of payment for almost half of the drugs
currently used to treat cancer.
- Some Insurance Companies Are Not Paying for the Medical
Costs Related to Clinical Research Trials. Many research
studies of "investigational" cancer therapies are conducted
by the National Institutes of Health, the National Cancer
Institute, and the Food & Drug Administration.
These studies provide patients with access to
promising new treatments that have not yet been approved by
the FDA for wide-spread use. The manufacturers of
investigational agents often provide the drugs free of
charge to patients on research studies. However, many
insurers are refusing to pay for the "standard" treatments
associated with these studies & other drugs, hospital
stays, office visits, laboratory tests, etc.
What Can Be Done If Payment Is Denied for Your Treatment?
Doctors and their office staffs will provide
insurance companies with the results of scientific studies
that prove a particular drug is effective treatment for your
type of cancer. Similarly, the staffs at hospitals and
cancer centers will provide insurance companies with
information to obtain payment for hospital stays, laboratory
tests, and so forth. Usually this is sufficient to handle
the problem and the claim is paid.
However, if the efforts of your doctor and other
professionals fail to obtain payment for your treatment,
they can obtain assistance from a number of reimbursement
specialists that operate "hotlines" for various drug
manufacturers. These specialists provide an array of
services, from literature searches of pertinent studies to
direct contacts with involved insurance companies.
In a number of states, cancer physicians have formed
organizations that are actively involved in educating the
decision makers at insurance companies about effective new
treatments for cancer. Some of these organizations are also
working with cancer patient advocacy groups to pass state
laws that require insurance companies to meet minimum
standards of coverage.
As a last resort, some cancer patients have
successfully sued their insurance companies to obtain
payment for their treatments. In many cases, the courts have
sided with patients who have been denied access to a new
technology or drugs and overturned the insurance company's
policy. Therefore, if all else fails, the legal route is one
How Can You Ensure That Your Insurance Plan Provides Adequate
Coverage for Cancer Treatments?
The best way to ensure that you have adequate
coverage for cancer therapy is to ask a variety of insurance
plans about their payment policies for cancer treatments
before you select a plan. Insurance plans vary widely as far
as the types of treatments they cover and, in many cases,
the language in insurance policies is vague with regard to
what treatments are covered.
Of course, sometimes you do not have a choice among
insurance plans. Your company may provide coverage through
only one company or it may be self-insured. And, even if
your company offers a variety of plans, it may not be to
your advantage to switch to another plan. For example, if
your cancer has already been diagnosed, many plans will not
cover the treatments associated with that "pre-existing"
If you do have a choice, it is important to find out
if your insurance plan meets certain minimum standards. Make
an appointment to talk to your insurance agent or the person
who is responsible for selecting health insurance or
coordinating health benefits at your company.
Take your representative a copy of the minimum
standards in this brochure. These standards can also be
useful to your insurance representative to evaluate both
current coverage and alternative insurance plans.
A Checklist for Action
- Your doctor will alert you if there is a significant
problem in obtaining payment for your treatment. Ask what
you can do to help.
- Inform your doctor or the office staff that reimbursement
specialists are available to provide, free of charge, a
variety of services, from literature searches to direct
negotiations with some insurers. Information on their
specific services and "hotline" numbers is available from
the Association of Community Cancer Centers.
- Contact your doctor or the Association of Community Cancer
Centers to find out if there is an Association chapter or
organization of cancer physicians in your state that is
actively involved in resolving reimbursement problems.
- If there is an active organization in your area, ask what
you can do to help ensure cancer patients have adequate
coverage for state-of-the-art treatments. There may be
efforts under way to pass uniform legislation. If not,
perhaps you know a potential sponsor for such legislation in
your State Senate or House of Representatives.
- Meet with your insurance agent or the health benefits
manager at your company to see if your current policy meets
the minimum standards set forth in this brochure. If it does
not, ask your representative about other available insurance
plans that provide better coverage.
- Urge your insurance representative or health benefits
manager to seek insurance coverage that meets the minimum
standards in this brochure.
These standards are endorsed by the Association of Community
Cancer Centers, the Oncology Nursing Society, and the National
Coalition for Cancer Survivorship.
Minimum Standards for Cancer Benefits in Insurance Policies
Coverage Should be Provided for All Cancer-related Drugs and
Therapies that are FDA approved and selected by a physician.
At a minimum, this includes all FDA-approved drugs
for all indications listed on the drug labor or package
insert and all indications listed in the following
authoritative medical references:
In addition, policies should provide coverage for
new procedures, drugs and technologies that have been
established by the scientific literature. New technologies
are considered standard therapy when scientific research
demonstrates their effectiveness in the treatment of
cancer. If there is confusion about what is considered
standard therapy or information on new technologies is
needed, there should be a provision in the policy that
requires insurers to contact a state association of cancer
specialists, or a local chapter of the Association of
Community Cancer Centers, for an evaluation of the therapy
- The U.S. Pharmacopeia Drug Information Guide for the
Health Care Professional (USP DI)
- The American Medical Associations's Drug Evaluations (AMA
- The American Society of Hospital Pharmacists' American
Hospital Formulary Service Drug Information (AHFS-DI)
In no case should an insurer deny payment on the
basis that a drug was used in combination with other
drugs. Many standard cancer drug treatments involve the
administration of more than one drug at the same time.
Special Payment Status Should Be Granted Drugs
Designated as Group 'C' Agents by the National Cancer
Institute and Drugs Granted 'Treatment IND' Status by the
These two categories of drugs are granted special
status because they have shown important clinical advantages
in the treatment of select groups of cancer patients, but
they have not yet achieved full approval by the FDA. Despite
the fact that they have not completed the FDA review
process, studies have convinced the NCI and the FDA that
theyshow more promise than other therapies available to
select groups of cancer patients and should be reimbursed.
Insurance Policies Should Cover the Standard Patient
Care Costs Associated with Patients Enrolled on Clinical
Trials Approved by the FDA and Any Agency Under the Auspices
of the National Institutes of Health.
Access to a clinical research trial provides
patients with the opportunity to receive the best available
therapy. All standard treatments associated with patients
enrolled on a clinical trial should be covered, including
diagnostic testing, hospital stays, physician office visits,
and so on.
For further information about these standard, contact:
The Association of Community Cancer Centers
11600 Nebel St., Suite 201
Rockville, MD 20852
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Breast Cancer Information