Affording Care

Affording Care

Figuring out what costs are covered by health insurance may feel overwhelming. This resource is designed to help you learn the basics about health insurance and provide you with some organizations that may help you be more informed and involved during your care.

KEY POINTS

  1. Before starting any treatment, it’s important to know what type of insurance you have and what your out-of-pocket costs will be
  2. Different parts of Medicare cover different services. When it comes to prescription drugs, there are 2 parts to think about: Medicare Part B and Medicare Part D
  3. It’s important to know that resources are available that can help you be more informed and involved during your care

Understanding Helpful Insurance Terms

What Type of Insurance Do I Have?

Before starting any treatment, it’s important to know what type of insurance you have. On your first visit, your doctor’s office will ask you if you have insurance. If you do, you’ll need to provide the office with your insurance card and prescription drug card, if you have one.

Here are examples of the most common types of insurance:

  • Commercial insurance is provided by your employer. It may also be part of your retirement package. Or, you may have bought insurance on your own through a healthcare exchange.
  • Medicare and Medicaid are health insurance plans that are provided by the government. If you are older than 65 years, you may be eligible for Medicare.

Uninsured means you don’t have health insurance. Underinsured means you have insurance, but it may not be enough to cover the cost of your medicine or treatment. If you don’t have insurance, there are still options available that may be able to help you with your treatment coverage.

Frequently Asked Financial Questions

What Will My Insurance Cover?

Once you know what type of insurance you have, you will be able to find out what your out-of-pocket costs will be for your treatments. Your doctor’s office can find this information for you.

What Are Your Out-of-Pocket Costs?

Out-of-pocket costs are what you pay out of your own pocket for your healthcare. Out-of-pocket costs may include:

  • Payments required to meet your insurance deductible
  • Any co-payments or co-insurance for which you are responsible
  • Any medical expenses that may not be covered by your insurance

What Is a Deductible?

Some insurance plans require you to pay a certain amount each year before they will begin to pay for your healthcare. This amount is called your deductible. Once you meet your deductible, your insurance begins to pay its share of your healthcare costs.

Is a Premium the Same as a Deductible?

A premium is different from a deductible. A premium is the amount you pay each month to your health plan for your health insurance. If you have commercial insurance and are employed, a percentage is usually taken out of your paycheck for this. Your employer may pay the rest. Your premium is not considered an out-of-pocket cost.

What Is a Co-payment?

Co-payments vary depending on your insurance plan. A co-payment is the flat dollar amount you pay out of your own pocket when you:

  • Visit your doctor’s office
  • Go to the emergency room
  • Pick up a prescription from a pharmacy

For example, a doctor’s office visit might have a co-pay of $15. For emergency room visits, co-pays are usually higher, such as $200. Prescription drugs usually have a co-pay as well. This amount varies depending on the medicine.

What If I Have Co-insurance?

Co-insurance is different from a co-payment. Co-insurance is the amount you pay after you have met your deductible, but instead of it being a flat dollar amount, the amount you pay is a percentage of the total cost of your healthcare.

For example, if you have a health plan with a 20% co-insurance amount, after you meet your deductible, you would pay for 20% of your healthcare costs and your health plan would pay the remaining 80%.

Can I Have a Co-Insurance and a Co-Payment?

Yes; depending on the type of insurance you have, you may have a co-payment and a co-insurance payment.

Does My Insurance Company Need to Approve My Medicine Before I Start It?

Insurance companies need to approve some treatments before you can start them. This is called prior authorization. Prior authorization can help determine if your insurance will pay for your medicine. Your doctor’s office can tell you if you need a prior authorization to start on a medicine.

For Patients Who Have Medicare

I have Medicare. How Much Will My Co-Payments Be?

Different parts of Medicare cover different services. When it comes to prescription drugs, there are 2 parts to think about: Medicare Part B and Medicare Part D. Part B covers intravenous (IV) and injectable medicines (like IV chemotherapy) that are provided in the doctor’s office. Part D covers oral and self-administered medicines.

For Part B, Medicare will pay 80% of the cost of the medicine (after you meet your deductible) for most outpatient services. You pay the remaining 20% of the cost. Many patients add supplemental coverage to their Medicare plans to help with these costs. If you can’t afford your Medicare Part B co-insurance, you can speak to your healthcare team to explore different options.

Part D plans have out-of-pocket costs, such as deductibles, co-payments, or co-insurance. These costs vary by plan. Part D plans also have a coverage gap, which is often called the “donut hole.”

What Happens When I Am in the Donut Hole?

When you are in the Part D donut hole, it means you and your insurance plan have reached the dollar limit that you and your plan pay for your drug coverage. In 2015, that amount is $2,960.

While in the donut hole, you are responsible for 45% of the cost of your brand-name drug(s) and 65% of the cost of your generic drug(s).

If you can’t afford your medicine, you can speak to your healthcare team to explore different options.

*Medicare Part D plans can vary in cost and drugs covered.

  • In the donut hole, you are responsible for 65% of the cost of your generic medication. Deductible and donut hole limits otherwise remain the same.

Additional Assistance

Your doctor’s office may have a designated person who can answer your insurance questions.

It’s important to know that resources are available that can help you be more informed and involved during your treatment. Here are some organizations that can offer you and your loved ones support.

American Cancer Society (ACS)
1-800-ACS-2345 (1-800-227-2345)
www.cancer.org

CancerCare®
1-800-813-HOPE (4673)
www.cancercare.org

Cancer Support Community
1-888-793-9355
www.cancersupportcommunity.org

Disability.gov
www.disability.gov

International Myeloma Foundation (IMF)
1-800-452-CURE (1-800-452-2873)
www.myeloma.org

Leukemia & Lymphoma Society (LLS)
1-800-955-4572
www.lls.org

Meals on Wheels Association of America
www.mowaa.org

Multiple Myeloma Research Foundation (MMRF)
1-203-229-0464
www.themmrf.org 

National Cancer Institute (NCI)
1-800-4-CANCER (1-800-422-6237)
www.cancer.gov

Caregiver Action Network
www.caregiveraction.org

Information about these independent organizations is provided as an additional resource for obtaining information related to multiple myeloma. It does not indicate endorsement by Celgene Corporation of an organization or its communications.

Your healthcare team is your best source of information.

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