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What if my insurance does not cover my cancer medications?

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Updated February 01, 2012

Question: What if my insurance does not cover my cancer medications?

My health insurance paid for my cancer surgery and hospitalization but will not pay for some of the medications prescribed by my doctor. I am especially worried because insurance will not pay for the chemotherapy drug my oncologist has recommended for me.

I work full time and do not qualify for any government assistance, even though my state's Medicaid program would pay for my medications. I simply cannot afford to pay out of pocket. I definitely cannot quit my job just to qualify for state insurance. Is there anything I can do?

Answer:

You certainly are not the only cancer patient whose health insurance lacks coverage for much-needed medications. The good news is that there are many programs available to help people with cancer bridge the financial gap between the cost of cancer treatment and their ability to pay.

Paying for Chemotherapy

First, you have the right to appeal your insurance company's denial of services. It can be a lengthy and emotionally investing strategy that does not guarantee results, but it is worth a shot. Some cancer patients have found success in appealing the denial of their insurance providers, while others have not. Since appeals are approved on a case-by-case basis, some cancer patients choose to hire a patient advocate to assist them in the appeals process. The process involves writing letters to the insurance company and gathering information from doctors and other medical professionals.

How to Fight an Insurance Denial

Most drug companies have patient assistance programs that will provide medications like chemotherapy to eligible patients. The eligibility criteria are not always based on income, so don't assume that because you are employed, you are ineligible. These programs were created for those without insurance and also for those whose insurance companies do not provide coverage of prescribed medications.

See which drug companies have patient assistance programs.

Applying to a drug manufacturer's patient assistant program usually requires an application and other paperwork that must be completed by your physician. Your oncologist's office likely is aware of the available programs and may be able to help you fill out the paperwork. Once complete, applications can often be mailed or faxed. Eligibility decisions are usually timely.

Paying for Other Medications

Unfortunately, medication for cancer treatment doesn't stop at chemotherapy. Many times, medications are needed to help manage treatment side effects. If the medication your doctor prescribed is not on your insurance provider's "formulary," ask your doctor if there is an acceptable substitute. You can always request your doctor to prescribe the generic version of the medication, if one is available.

If paying out-of-pocket for medications, it is prudent to compare prices at different pharmacies. Not all pharmacies sell medications at the same price. In fact, the difference can be substantial, potentially saving you quite a bit of money. Simply call the pharmacy and tell them what drug you want, the dosage and quantity, and ask for the cost. It is common for customers to check pharmacy prices, so don't feel uncomfortable doing so.

You may be tempted to use online pharmacies that boast unbelievable prices for prescription drugs. Most of the time, if it sounds too good to be true, then it probably is. Many online pharmacies, especially from other countries, sell "bootleg" versions of drugs. The drugs do not come from the brand manufacturer and can contain unidentified ingredients that may harm you.

Is It Safe to Buy Drugs from Online Pharmacies?

If the cost of your non-chemo drug exceeds your budget, you can always see if you can participate in a prescription drug assistance program, such as the one described above for chemotherapy drugs. Many drugs are covered under this program; it is not exclusive to chemotherapy medications.

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