There are 2 general types of health insurance: private sector coverage and public
Private Sector Health Insurance (Also Called Commercial Health Insurance)
Private insurance can be employer-sponsored or bought directly by an individual.
It allows you to get health care and may protect you from the potentially high costs
of medical care.
Often there are different private insurance options to choose from. Examples of
private health plans include:
- Health Maintenance Organizations (HMOs), some of which may be called point-of-service (POS) plans
- Preferred provider organizations (PPOs)
- Conventional health plans
Public Sector Health Insurance (Also Called Government Health Insurance)
Many consumers are enrolled in government insurance plans. These are also called
publicly sponsored health insurance plans. They include Medicare, Medicaid, Veterans
Affairs, and Military—TRICARE.
Medicare is a health insurance program run by the Centers for Medicare & Medicaid
Services (CMS). It is available for
- People age 65 or older
- People under age 65 with certain disabilities
For more information about Medicare, visit http://www.medicare.gov
Medicaid is a joint federal-state insurance program. It is run by individual states
for individuals with limited income. Because each state operates these services,
rules and eligibility may differ.
These are some factors considered when determining Medicaid eligibility:
- Whether or not you are blind or disabled
- Citizenship status
Regardless of the requirements, many people are eligible for these services. If
you are uncertain whether you fit Medicaid criteria and are in need of care, you may want to consider
applying for these services. For more information about Medicaid and the services
it provides, call your state Medicaid office or go to www.cms.hhs.gov/MedicaidGenInfo.
The United States Department of Veterans Affairs (VA) provides a medical benefits
package. It includes a standard enhanced health benefits plan for all enrolled veterans. A priority system ensures that veterans with service-connected disabilities can
enroll. It also ensures enrollment for those below a low-income threshold.
Services typically include:
- Emergency inpatient care in VA facilities
- Medical for diagnostic and treatment services
- Surgical (including reconstructive/plastic surgery as a result of disease or trauma)
- Mental health diagnostic and treatment services
- Substance abuse diagnostic and treatment services
- Prescription medications
- Over-the-counter medications
- Medical and surgical supplies
Military – TRICARE
TRICARE is a military health care program that provides service worldwide to:
- Active duty service members
- National Guard and Reserve members
- Their families and survivors
- Certain former spouses
To be eligible for TRICARE benefits, you must be registered in the Defense Enrollment
Eligibility Reporting System.
Just like other insurance programs, TRICARE covers most inpatient and outpatient
care. As with most insurance, there are special rules, limits, and noncoverage
for certain types of care. For example, you may also need to gain preapproval or prior authorization.
And you may have co-pays for select services and treatments.
Most health insurance plans divide coverage into 2 categories: medical benefits
and pharmacy benefits.
Normally the medical benefit covers and manages treatments given by a medical professional.
These include most intravenous (IV) chemotherapies and newer biological agents.
Pharmacy benefits differ from medical benefits coverage in many ways. Products covered and managed under the pharmacy benefit are governed by formularies.
These guidelines are developed by the insurance company in conjunction with a Pharmacy
& Therapeutics (P&T) Committee. They set policies for the access, coverage, and
reimbursement of each medication that is part of the formulary.
Regardless of the insurance type, many people have some type of coverage to fill
gaps in their insurance benefits. This is called secondary or supplemental insurance.
It is used after filing a claim with the primary insurer.
Within Medicare, the leading source of supplemental coverage is either employer-
or union-sponsored plans. These plans often lower potential out-of-pocket expenses
for beneficiaries requiring health care benefits.
Other sources of secondary coverage:
- Medicare Advantage plans. These often provide additional benefits, including prescription
drug coverage at lower costs.
- Medigap policies. These are sold by private insurance companies to fill gaps in
the benefits. They assist with co-insurance, co-payments, and other Medicare deductibles.
Benefits investigation is a process that a health care practice or provider undertakes
before prescribing or administering any medication. It ensures that the medication
you are prescribed and/or administered will be covered or reimbursed by your insurance
company. During this process, the office, a specialty pharmacy or a dispensing
pharmacy, contacts your insurance company. They do this to gain approval for prescribing
and/or administering the product.
If the reimbursement creates unacceptable patient out-of-pocket expenses, they may
seek additional support. This could be from a patient assistance program or secondary
insurance coverage. They may also prescribe another agent. This helps to reduce
a potential treatment roadblock, allowing the physician to administer the full course
If you are receiving TORISEL, the
First Resource® Reimbursement Support Services can also help
your doctor’s office investigate your benefits. Ask your doctor about these services.
Prior authorization (PA) is a process in which a health plan determines whether payment for a product prescribed by a physician will be covered.
Prior authorizations are generally in place to ensure drugs are given to patients only after they have met certain criteria set by the health plan. A PA can be enforced in various ways, such as
- Requiring failure of a generic agent prior to the prescribing of a branded agent
- Confirming an agent is being prescribed by a medical specialist
- Limiting quantities
For agents requiring prior authorization, the physician and his or her staff will
contact the insurance company and submit a claim for the product. This explains
to the insurance provider why the product is medically necessary for a specific
At times, certain services or products will not be covered as part of your benefits
package. If you believe you should receive coverage but are being denied, you can
challenge the decision. You do this by filing an insurance appeal. This is possible
because there are a variety of regulations and laws governing insurance. These laws
are set by states to ensure that patients receive the benefits they believe are
covered within their insurance policy.
Your doctor’s office will typically handle your insurance appeal. In some cases,
you may be asked to get involved. Below are some tips to help you handle this process:
- Obtain access to your benefits contract from your employer or contact the plan’s
member services department. Do this to find out what is and isn’t covered in your
- If after reviewing your benefits you believe you have a claim, you should contact
the plan to see how the appeals process works. There isn’t a standard process nationally.
- Once you understand the process, you can begin to file your claim in writing. Keep
a detailed account and follow through on each step of the process.
You may even wish to ask your physician for support with this process. If you are
receiving TORISEL, the Pfizer First Resource®
Patient Assistance Program can also help you and your doctor’s office investigate
If the appeal is not resolved to your satisfaction, you can contact the state insurance
board or health department.