POLICY COVERAGE ON PRESCRIPTION DRUGS AND POST-TREATMENT RECONSTRUCTION ITEMS AND SURGERIES
When you have a chronic illness such as breast cancer, medical care costs may account for most of your total financial expenses. Among all medical care, prescription drugs and medical items such as wigs or prostheses, are one of the most expensive. Therefore, you need to understand the extent to which your insurance policy covers your medication and any other associated expenses. Here are the terms you must take notice of:
PRESCRIPTION DRUG
You must pay attention to exactly what and how many of your medications does your policy covers. Also, when your policy “covers” a prescription drug, does it mean the insurance company pays the full price? Or do you have to co-pay? Do look out for these details:
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Formulary: This is the list of prescription drugs covered by your policy. Drugs are filled into different tiers (cost level). Drugs of higher tiers are more expensive, so the insurance company will cover less of the prices.1,2
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Generic drugs and some Branded drugs (Tier 1 to 2): Branded drugs are sold by the company that created and tested them.2 Generic drugs contain the same active ingredients in the same amount as the branded version, but other inactive ingredients such as fillers may differ, potentially affecting the rate of absorption or cause different side effects in some cases.3 Repeated animal and clinical studies are also not required to demonstrate efficacy and safety as part of the generics' approval process.4 Although generic drugs are generally cheaper, you should consider other factors beyond the price and seek professional advice from your doctor.
- More expensive branded drugs (Tier 3)2
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Specialty Drugs (Tier 4): Expensive drugs for treating complex and/or chronic illnesses. You can find most cancer medications in this tier.2
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Off-formulary drugs (Tier 5): Not covered by policy. You will have to pay 100% for these drugs. The costs will NOT be counted as OOP costs.2
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Exceptions to Formulary: Your insurance company will not cover off-formulary drugs. However, you can file appeals for several reasons (i.e. allergic reactions; negative interactions between drugs).2
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Tier Exception: for when you need a prescription drug, but said drug is filled in a higher tier. Reasons for exceptions can include allergic reactions to the drug, the drug has known adverse interactions with another medication you are taking, or you have previously tried the drug without any results.1,2
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Brand Exception: for when you need a branded drug for a specific reason, even though a generic alternative exists.1,2
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Non-formulary Drug Exception: for when your doctor prescribes an off-formulary drug, and there isn’t an alternative drug covered.1
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Step Therapy: When you have been prescribed a drug of higher tiers, your insurance company may require you to try a cheaper drug first.1,2
If you and your doctor are certain the cheaper drug does not work for you, your doctor can request your insurance company to cover the prescribed drug right away.2
ITEMS FOR POST-TREATMENT SIDE EFFECTS AND RECONSTRUCTION
You may need some items to deal with the side effect of cancer treatment and surgeries. These side effects, such as hair loss and lymphoedema, may extend into post-treatment recovery. You may also want prostheses and/or surgeries for reconstruction.5
Unlike prescription drugs, “medical goods” such as wigs, mastectomy bras, and lymphedema compression garments are not as consistently covered by health insurance companies. Some insurance companies may co-pay for these medical goods.5
Unfortunately, breast reconstruction surgery is not covered by most insurance companies. That being said, exceptional cases exist in which the surgeon states the surgery as a “medical necessity” (i.e. possible back and posture issues in the future for the patient). Ultimately, you are advised to read the policy carefully and contact your health insurance agent for the most accurate information. 6
