During the Lymphoma Research Foundation’s Denver Ask the Doctor About Lymphoma Program, lymphoma-expert and program host, John M. Burke, MD (Rocky Mountain Cancer Center), provided the following answer to this question: How can patients access innovative drug treatments when insurance won’t cover the cost?
Many Americans and medical professionals have expressed their concerns over the years regarding the rapidly rising costs of cancer drugs. In 2017 the American Society of Clinical Oncology (ASCO), a professional organization that many oncologists are members of, released a position statement expressing concern about the high prices of oncology drugs, including the problem of high out-of-pocket expenses borne by patients.
Patients have undoubtedly felt the impact of such high costs; studies have demonstrated that a significant number of patients have accrued debt, been forced to sell or refinance homes, had to borrow money from family or friends, and experienced a considerable decline in income due to the cost of cancer treatments. Some patients have even had to reduce spending on food and clothing in order to afford treatment. Others have been forced into bankruptcy. Still, others will decline treatment entirely to avoid having to incur such expenses.
One way that patients can get access to new drug treatments is by enrolling in clinical trials. In oncology, clinical trials, drugs that are considered “standard” for a disease are billed to insurance, with the patient potentially being responsible for part of the cost. However, drugs that are considered “investigational,” or not standard, are generally provided for free. Such investigational drugs are usually not yet approved by the FDA, or at least not for that particular circumstance, and therefore usually will not be paid for by insurance companies outside the setting of a clinical trial.
What about drugs that have been vetted through the research process and now are FDA approved? Typically, such drugs will be covered, at least partially, by insurance companies. That said, patients may still be responsible for part of the cost of those drugs. For example, if a drug costs $20,000 per month, and a patient’s insurance plan requires that the patient pays for 20 percent of the cost of the drug, then the patient may be responsible for $4000 per month, which of course is unaffordable for most people.
The primary way that oncology practices help patients mitigate such costs is through “patient assistance programs.” The way these programs work is as follows:
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- I (the hematologist/oncologist) prescribe medication or a combination of medications for a patient.
- The staff of my practice submits the request to the patient’s insurance company.
- The insurance coverage and the patient’s expected out-of-pocket costs are determined.
If the patient’s out-of-pocket costs are more than he or she can afford, we will try to identify financial assistance programs that can assist the patient in covering the costs. Sometimes the financial assistance will come from a charitable organization like the Lymphoma Research Foundation. Other times pharmaceutical companies that manufacture the prescribed drug will offer such financial support. Oncologists’ offices generally know how to access these types of resources for patients. Usually, patients will have to submit personal financial information – such as recent income tax returns and income statements – for review by the organization that is considering providing financial assistance. Patients wishing to learn more on their own can access webpages of pharmaceutical companies that provide such financial support.
Hematologists and Oncologists utilize a highly trained team of clinicians, nurses, and financial counselors to ensure patients have access to innovative drug therapies. We also leverage experienced pharmacists to review therapies and resolve potential insurance coverage issues when new drugs become available. This collaborative effort is all behind the scenes and each situation and the insurance company are different. While the process may take some time, the team is committed to pursuing all possible avenues to get the therapy approved, and if available, obtaining additional copay assistance to decrease the overall out-of-pocket cost responsibility of the patient.
The Lymphoma Research Foundation (LRF) offers a Patient Aid Program for people currently undergoing treatment for lymphoma. To learn more about this program visit lymphoma.org/financialsupport.
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