Targeted Therapy

+ -Text Size

TOPICS

Paying for targeted therapy

How do I pay for my treatment?

The cost of targeted therapy varies with the drug used, how it’s given, how long and how often it’s given, and whether you get treatment at home, in a clinic, office, or hospital. Your cost will also depend on what other treatments are given, such as radiation or standard chemotherapy (chemo) drugs. Many targeted drugs that you take by mouth are very expensive, and can reach costs of thousands of dollars per month. They may be covered under your prescription drug benefit rather than your cancer chemo benefit, so that you may end up paying more out of pocket.

Most health insurance policies, including Medicare (Part B and D), cover at least part of the cost of most kinds of targeted therapy and chemo. But to reduce their costs, companies often don’t pay for every drug. Before you start treatment, find out whether your health insurance will pay for your medicines, and how much they will pay for any targeted drug you take by mouth. If it’s too costly for you, ask your doctor about getting help from the drug company. To learn more about getting this kind of help, see our document called Prescription Drug Assistance Programs.

For more information on how to control your finances so you can better focus your energies on treatment and recovery, see our booklet called In Treatment: Financial Guidance for Cancer Survivors and Their Families.

What do I need to know about insurance coverage?

Insurance companies may deny payment for targeted therapy and/or chemo for these reasons:

  • They may not be aware of new treatments.
  • They may limit the selection of drugs that doctors can use.
  • They may restrict payment to the uses first approved by the Food and Drug Administration (FDA).

If you are going to take part in a clinical trial, find out if your insurance will cover any of those costs, too. Health plans that start in 2014 or later are required to cover most of the costs for those in clinical trials for serious health conditions. Still, coverage of clinical trials varies state to state in older “grandfathered” insurance plans, and insurers may deny payment.

If your insurer denies payment for your treatment, don’t give up. There are ways to appeal these decisions. You can learn more about health insurance in our documents called Health Insurance and Financial Assistance for the Cancer Patient and Children Diagnosed With Cancer: Financial and Insurance Issues.

What do I do if my health care claim is not paid?

Before you appeal, you may want to take these steps:

  • Ask your customer service representative for a full explanation of why the claim was denied.
  • Review your health insurance plan’s benefits.
  • If your plan is through your or your spouse’s employer, contact your health plan administrator at work to find out more about the refusal.
  • Contact reimbursement specialist hotlines at the pharmaceutical company that makes the drug for which payment was denied (ask your doctor’s office the drug name and which company makes it). People there are specially trained to help with insurance issues that may come up with “their” drugs.
  • Tell your health care team if you have been denied payment so that they can contact your insurer and help answer any questions.
  • Ask your doctor’s office staff to give your insurance company the results of scientific studies showing that a certain drug works for your type of cancer.
  • Keep a record of dates, names, and conversations you have about the denial.
  • Put off payment until the matter is resolved. Keep the originals of all the letters you get; your cancer care team may be able to help you make copies if you need them.

If this doesn’t work, request an internal appeal (or internal review) which is done by the insurance company. Your cancer care team may be able to help with this. You have 6 months (180 days) from receiving your claim denial to file an internal appeal. If it’s still denied, you can request an independent external review of the decision.

You can read more about appealing a claim denial in our document called Health Insurance and Financial Assistance for the Cancer Patient. You can also contact your hospital’s social service office, which may be able to direct you to other sources of help.

And the American Cancer Society can help you, too. Contact us anytime, day or night, for cancer-related information and support. Call us at 1-800-227-2345 or visit www.cancer.org.


Last Medical Review: 07/12/2013
Last Revised: 07/12/2013