As you begin treatment, it is important for you and your family to understand the extent of your insurance coverage. You should first turn to your insurer or benefits department to clarify your insurance and reimbursement questions. Secondarily, you can speak with your healthcare team and their billing and support staff. They will work closely with your payer (ie, your insurance company, HMO, Medicare, or Medicaid office) to determine what expenses are covered and what information is required. The information below may help you understand your coverage and learn more about programs that can help you.

Frequently Asked Questions
Help From GSK
Help From America’s Pharmaceutical Companies
Help From the Government
Other Resources for Help

Frequently Asked Questions

Is my policy currently in effect?

If you have paid your premiums on time, your policy should be in effect. Your cancelled checks are your best records for any policies you arranged for. If you’re covered by an employer’s coverage, the benefits manager should be able to answer your questions.

Does my policy cover diagnostic and lab tests?

There are some newer tests that may not be covered by your policy. You should ask your insurer whether they cover the tests your healthcare team recommends before you agree to or proceed with a test. Also talk to your healthcare team about your coverage concerns and about alternative tests.

Does my policy cover cancer treatment?

Some policies have exclusions where they specifically state they will not cover certain illnesses. Contact your insurer to clarify what is covered and what is excluded by your policy.

What is a preexisting condition clause?

If your cancer was diagnosed before your policy became effective, this may be considered a preexisting condition. Some plans deny coverage for an illness that was previously diagnosed. Other plans deny coverage for a predetermined length of time (usually 6 months or 1 year) and may even require that an individual be “treatment free” during the waiting period to qualify for coverage. During a preexisting condition waiting period, your insurance company may not pay for any care you receive related to your cancer. As a result of a law passed in 1996, any preexisting condition exclusion period must be reduced by the period of time the individual has maintained health insurance coverage, without a break of 63 consecutive days or more immediately before enrolling in the new health insurance. This could mean immediate coverage and payment for your treatment.

Is chemotherapy covered in an outpatient setting (doctor’s office, hospital outpatient, clinic, etc)?

In many cases your cancer treatment will include drug therapy along with your chemotherapy. Most plans cover chemotherapy provided in an outpatient setting. Private insurance plans (for example, Aetna, Blue Cross, and Blue Shield) generally cover chemotherapy under a major medical benefit. In addition to chemotherapy, major medical benefits usually include coverage for doctors’ services, diagnostic tests, laboratory services, etc. Medicare covers chemotherapy under its Part B program. Part B also covers doctors’ services, diagnostic tests, durable medical equipment, ambulance services, and other health services and supplies not covered under the Medicare Part A program. State Medicaid programs usually cover chemotherapy under the doctor or pharmacy program. Please see the links to learn how GSK can help, to get help from America’s pharmaceutical companies, or to find other resources that can help.

Is prior approval or preauthorization required?

Some plans, especially health maintenance organizations (HMOs) or preferred provider organizations (PPOs), require the doctor to ask and obtain permission before ordering a test or starting treatment. You should find out whether your insurer requires preapproval or prior authorization before you begin treatment. Your benefits manager, insurer, or healthcare team may be able to assist you.

Is the physician or hospital “participating,” “approved,” or “in network”?

Some plans, especially HMOs and PPOs, either require you to receive care from a doctor, healthcare provider, or entity who has signed a contract with the payer, or make you pay more money for using a doctor who is not in the plan. Let’s say, for example, your doctor participates in your insurer’s PPO. The insurance may pay 80% and you would be responsible for paying the remaining 20%. However, if you are treated by a doctor who is not a participating provider, your payer may cover less than 80%—probably closer to 60% (of the “reasonable and customary” charges). That would mean you would be responsible for paying the remaining 40% of the bill.

Are my drug treatments covered by my policy?

In order for payers to make reimbursement decisions about any specific therapy, they may want to know more about it. For example, you may hear your payer or healthcare provider discuss the following:

• Whether the use of that drug has been approved by the FDA
• Whether an insurance or billing code has been assigned for that use
  Most insurance companies require doctors to use special billing codes when they submit an insurance claim for medical products or procedures. These codes tell things like the patient’s diagnosis and what services were provided. Payers can then use this information to confirm that the service is the right thing to do for the illness.

What can I do to protect my current insurance coverage?

• Keep your policy current. Make sure you pay your premiums on time.
• Plan ahead. Know your policy. Be alert to coverage and benefit limitations, so you can make plans. When you are 18 to 24 months from termination or exhaustion of benefits, begin looking for new insurance or making arrangements for new coverage.
• Educate yourself. Study your policy and learn insurance terms so you can speak knowledgeably to the payer about your needs. If you cannot understand your policy or just don’t have time to read it, you should contact your benefits manager or your insurer or ask a family member or friend for help.
• Be aware. Track your expenses. Know what expenses are charged to your plan and ultimately to you. The explanation of benefits (EOB) or remittance advice received from your payer should provide details about submitted charges and the amount allowed and paid.
• Join a support group. Having other people to talk to who are facing similar problems and issues, and sharing information, is extremely helpful. Strength grows from numbers. Speak with your doctor and other providers about such programs. Also, contact the American Cancer Society at (800) ACS-2345 or The Wellness Community at (888) 793-WELL.
• Look for organizations that may be able to help you.

What is “open enrollment”?

Many states offer an open enrollment period, which lets people who are considered high risk or those with preexisting conditions buy individual health insurance policies. Contact your state Department of Insurance for more information.

Back to top

Help From GSK

GSK Reimbursement Resource Center

The GSK Reimbursement Resource Center is a toll-free reimbursement support program available to assist patients and healthcare professionals in the United States with coverage, coding, and reimbursement issues for certain GSK products. For more information, call (800) 745-2967 or visit the Center’s Web site at rrc.gsk.com.

GSK for You

GSK is here to assist you with your prescription drug coverage needs. Visit the GSK for You Web site at www.gskforyou.com to see if you may be eligible to save on your prescription drugs. GSK for You features information on patient assistance programs from other resources, too. We want to help you to get the drugs you need, even if you don’t take our medicines.

If you have questions about GSK savings offers or any of the other patient assistance programs featured on the GSK for You site, call us toll-free at (866) GSK-FOR-U (866-475-3678). Trained staff members are available weekdays from 8:00 AM to 8:00 PM, Eastern time to take your call.

GSK Commitment to Access

Commitment to Access provides free GSK oncology medicines to eligible low-income patients without prescription drug benefits. Patients must meet certain eligibility criteria to qualify for assistance and must enroll in Commitment to Access with the help of an Advocate. All GSK oncology medicines are offered for use in an outpatient setting. For more information, visit the Commitment to Access Web site at www.commitmenttoaccess.com.

GSK Bridges to Access

Bridges to Access, GSK’s patient assistance program for nononcology medicines, provides GSK prescription medicines to eligible low-income patients without prescription drug benefits or Medicare Part D. For more information, visit the Bridges to Access Web site at www.bridgestoaccess.com.

Back to top

Help From America’s Pharmaceutical Companies

Partnership for Prescription Assistance Program

The Partnership for Prescription Assistance offers a single point of access to more than 475 public and private patient assistance programs, including more than 180 programs offered by pharmaceutical companies. The program’s mission is to increase awareness of patient assistance programs and boost enrollment of those who are eligible. For more information, visit the program’s Web site at www.pparx.org or call (888) 4PPA-NOW (888-477-2669).

Back to top

Help From the Government

Federal Programs

Am I eligible for Medicare?

Medicare is a federally funded program designed mostly for the aged and permanently disabled. You may be eligible for Medicare if you are over 65, or under 65 and with one or more of the following:

• Social Security disability, and have been receiving Social Security income for 24 months
• Railroad retirement disability benefits
• End-stage renal disease benefits

Medicare Supplemental Plans

Medicare Supplemental Plans, called Medigap, are offered by private insurance companies, not the federal government. These plans help patients with medical expenses not covered by Medicare. For example, they will pay the remaining 20% after Medicare pays 80% for such services as chemotherapy provided in an outpatient setting. Contact a private insurance company (for example, Blue Cross or Blue Shield) for more information on Medigap plans.

Are there laws that affect my insurance coverage?

Consolidated Omnibus Budget Reconciliation Act (COBRA)

COBRA is a federal law that requires employers of 20 or more people to offer a temporary extension of health coverage if a person:

• Works fewer hours
• Loses his or her job (for any reason other than gross misconduct)
• Gets divorced from, or becomes legally separated from, a partner who has the medical insurance, or if the partner with the insurance dies
• Becomes eligible for Medicare benefits
• Loses dependent child status under an existing policy

COBRA can extend the benefits for 18 to 29 months, depending on the situation. The employer is required to notify the worker of the availability of this benefit. If you need more information, contact the personnel or insurance department at your company, or call the Department of Labor at (202) 219-8776. You can also visit their Web site at www.dol.gov.

This measure addresses such issues as waiting periods between jobs, coverage for small companies, and coverage for the self-employed. A person changing jobs may be denied coverage under an employer’s health plan for an existing health problem for up to a 1-year waiting period. Under the law, however, any preexisting condition exclusion period must be reduced by the period of time the individual has maintained health insurance coverage without a break of 63 consecutive days or more immediately before enrolling in the new health insurance. In other words, if you worked at the XYZ Company for 5 years and had medical insurance all that time, the new insurance plan cannot make you wait a year before your insurance kicks in. The law also prohibits group health plans from denying coverage or charging extra to cover an individual due to an existing medical problem. And finally, the law requires insurers to offer health insurance coverage to qualifying people who were covered under a group plan before and are now seeking insurance as self-employed individuals.

HIPAA also sets a national standard for accessing and handling medical information and gives you rights over your health records. It applies to past, present, and future mental and physical health information. Under HIPAA, your rights include: to see and get copies of your health records; to have corrections made to your health records; to receive notice on how your health records may be used and shared; to decide if you want to give permission for your health records to be used or shared (eg, a patient usually must sign a form or tell his or her doctor or clinic to share information with friends or family); and to get a report on when and why your health records were shared. If you believe your rights are being denied or your health records are not being protected, you can file a complaint with your provider, your health insurer, or the US government. You should know these important rights and ask your provider or health insurer questions about your rights.

Some states, such as California and Texas, expand the privacy protections that currently exist under federal law. This means that if you live in one of these states, you may also have to give permission to patient groups or other organizations to send you disease or treatment information.

State Programs

Are there any state programs I should know about?

Some states have passed laws requiring private insurance companies to reimburse for cancer drugs when the medical literature shows they are safe and effective. For example, ABC drug might be FDA approved for treating lung cancer, but scientists have shown that it is also good for treating liver cancer, so many doctors use ABC to treat liver cancer. You will need to contact the appropriate agency in your state for more information. You can also ask your healthcare team or visit the organizations that can help page for assistance.

Am I eligible for Medicaid?

Medicaid is a state medical assistance program. Each state has its own rules on who will get help, but usually only financially needy persons without any other type of insurance are eligible. Contact your state Department of Public Welfare or Department of Social Services for more information.

What rules apply to Medicare HMOs?

If you receive Medicare benefits through a Medicare HMO, your HMO has to follow the rules and procedures set down by the Department of Health and Human Services. Like any insurance program, these rules cover issues like how much will be paid for office visits, drugs, medical procedures, therapy, and so on. Your Medicare HMO is required to notify you any time they will be denying your coverage. They have to tell you if:

• Your treatment will not be paid for
• Your treatment will be only partially paid for
• They will not provide a particular treatment
• They will be providing less treatment, or
• They will not treat you any more

They also have to give you written information on your rights to an appeal and how to go about it, including any deadlines you may have to meet when you have to provide documentation.

State assistance programs
In addition to Medicaid, many states have other medical benefit programs for people in need. These are fully state funded and vary by state. You can investigate them by calling your state Health Department.

Back to top

Other Resources for Help

What else can I do to help cover the cost of my treatment?

• Change your existing policy. If you had coverage under your employer, you may never have considered being added to your spouse’s policy, or vice versa. You may now want to consider this if it will expand your coverage or protect you from possible loss of coverage due to maximum benefits.
• Convert your policy. Some group plans allow conversion of the policy, which means while you have exhausted your benefits through the group plan, you can purchase individual coverage under the same group plan by paying the premium for your policy. This may be a good strategy, and can be explored with your benefits manager. The premiums may be high, and the benefits may not be as complete as those of the group plan. Evaluate the cost of the premium versus the benefits, especially the lifetime maximum.
• Relocate or change employment. While it may be difficult to think about moving your family, you may find that more favorable insurance coverage is offered in another state. For example, you may not be able to purchase a policy from Blue Cross/Blue Shield in your state, but in another state Blue Cross/Blue Shield may offer guaranteed acceptance with a high lifetime maximum benefit. Changing jobs may be risky because of loss of coverage. However, if you intend to look for new employment, question employers about health insurance benefits and coverage for preexisting conditions. The insurance coverage offered by a new employer may be more comprehensive or may allow you to start over with a new lifetime maximum allowance. This is particularly true if you move from a small employer to a large one. If you are required to join a trade union in connection with your job, and your insurance is available through a union trust, you may want to discuss a higher lifetime maximum benefit with your coworkers and union steward as an additional benefit to address when contracts are considered for renegotiation.
• Become a member of an organization offering a group policy. Many fraternal and professional groups (for example, Rotary Club and the Chamber of Commerce) make large-group coverage available. You may find that clubs or special-interest organizations to which you already belong offer coverage. Examine the benefits and lifetime maximum. While premiums may be reasonable, the benefits and lifetime maximum may be low or restricted.
• Contact compassionate organizations. Nonprofit organizations and local fundraisers are formed to address individual or group health needs. The dollars raised may be given to a healthcare provider for a particular patient’s medical bills that cannot be paid because of lack of insurance, or may be used to pay insurance premiums for people who cannot otherwise afford to do so. Some of these programs may have waiting lists or requirements that prevent immediate sign-up. So, if you think you need help now or will need it soon, look into these options now. Don’t wait. Click here for a list of organizations that can help.

Back to top

Next -> Organizations That Can Help