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Cancer and Insurance


Neverstopfighting

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Hey all,

I've been admitted to a clinical trial at my hospital.  I am afraid if my insurance company finds out, that they will no longer cover my meds.  Is this a valid fear?  What can I share with them?   What can I share with the pharmacy that sends me the meds that are covered?  I understand that there is a federal law that prevents insurance companies to 

Per cancer.gov:  Also, if you do join an approved clinical trial, most health plans cannot refuse to let you take part or limit your benefits.

Still, I'm worried they will find a loophole and try to take advantage.  

Any info would help.

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Hi Joe-

Those are legitimate questions.  I worked as an insurance executive for a number of years however, I don’t know how the coordination occurred with the clinical trials. 

I would start with the hospital finance team first.  Then I would schedule an appointment with your team pharmacist ( you should have one assigned directly to you).  The PharmD might know. This isn’t the first time the question will have come up.

You may want to ask the Insurance Advocate at the employer.  These individuals are supposed to be experts in understanding the “Specific Plan Documents”   This explains the employer coverage   You will need to understand if the policy is ASO (Administrative Service Organization) or Fully Insured (meaning the health plan manages the finances on a profit loss basis)  ASO contracts are better as the employer has the fiduciary authority to make coverage decisions.  

The Insurance company is a resource of last resort. The people who are answering the phones only know how to give scripted answers. 

Let us know what you find out.  Be patient- the Insurance is worse than the disease!!!

Michelle

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If you can tell me a little about your insurance, I can at least point you towards the requirements in New York. I've been in the industry for almost 28 years and I'm a product design & compliance consultant. Is your policy an individual policy that you purchased on your own or are you covered under a group policy? You can send me a private message if you would prefer.

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