Cancer Treatments
Your Insurance Should Cover

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Information for Patients And Their Families

Sponsored by:
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 families, including:

  • Why insurance companies are denying payment for effective cancer treatments

  • 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

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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 Congress.

    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.

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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 to consider.

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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" condition.

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.

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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.

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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:

  • The U.S. Pharmacopeia Drug Information Guide for the Health Care Professional (USP DI)

  • The American Medical Associations's Drug Evaluations (AMA DE)

  • The American Society of Hospital Pharmacists' American Hospital Formulary Service Drug Information (AHFS-DI)

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 in question.

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 FDA.

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
Phone: 301-984-9496
Fax: 301-770-1949

The electronic version of this document was created by NYSERNet, Inc. through a grant funded by the New York State Science and Technology Foundation as part of the Breast Cancer Information Clearinghouse.

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