Understanding Insurance: An Overview

Many factors affect health care access and insurance coverage. In this section you’ll find a brief overview of the insurance industry. It includes types of coverage you may have and how the overall benefits process works.



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Types of insurance


There are 2 general types of health insurance: private sector coverage and public sector coverage.


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
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
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:

  • Age
  • Whether or not you are blind or disabled
  • Income
  • 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.


Veterans Affairs
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
  • Retirees
  • 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.


Medical and Pharmacy Benefits

Most health insurance plans divide coverage into 2 categories: medical benefits and pharmacy benefits.


Medical 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
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.


Secondary Coverage & Supplemental Policies

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


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 of therapy.

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


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 patient.


Insurance Appeals


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:

  1. 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 insurance package.
  2. 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.
  3. 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 your benefits.

If the appeal is not resolved to your satisfaction, you can contact the state insurance board or health department.


Indication

TORISEL is indicated for the treatment of advanced renal cell carcinoma.


Important Safety Information

  • You should not receive TORISEL if certain tests show that your liver function is moderately or severely impaired. TORISEL should be used with caution in patients whose liver function is mildly impaired and should be given at a reduced dose.
  • TORISEL can cause serious side effects. If you experience side effects that are too severe to tolerate, your health care professional may choose to delay your treatment, give you a lower dose of TORISEL, or discontinue treatment.
  • Before you begin treatment with TORISEL, your doctor may give you an antihistamine. It is possible to have a serious (including a life-threatening or fatal) allergic reaction even after you receive an antihistamine. Tell your doctor or nurse if you are allergic to antihistamines or are unable to take antihistamines for any other medical reasons. Tell your doctor or nurse if you have any swelling around your face or trouble breathing during or after treatment with TORISEL.
  • Patients are likely to experience increased blood sugar levels. This may require treatment with or an increase in the dose of a medicine that lowers blood sugar levels. Tell your doctor or nurse if you are thirstier than usual or urinate more often than usual.
  • Patients are likely to experience an increase in cholesterol and/or triglycerides. This may require treatment with or an increase in the dose of a medicine that lowers cholesterol and/or triglycerides.
  • Before you begin treatment with TORISEL, tell your doctor or nurse about ALL MEDICINES you are taking, including
    • Prescription medications, including but not limited to antibiotics, anticonvulsants, antidepressants, antifungals, antivirals, blood pressure medications, blood thinners, dexamethasone, vaccines
    • Nonprescription (over the counter) medications
    • Vitamins
    • Herbal supplements, including but not limited to St. John’s Wort
  • Avoid eating grapefruit or drinking grapefruit juice during the course of your treatment with TORISEL, including the time between treatments, as they may change the amount of TORISEL in your body.
  • Treatment with TORISEL may affect your immune system. You may be at greater risk of getting an infection while receiving TORISEL.
  • Patients may get chronic inflammation of the lungs during treatment with TORISEL. Rare fatal cases have been reported. Tell your doctor or nurse right away if you have any trouble breathing, or develop a cough or fever.
  • TORISEL may cause bowel perforation. Fatal cases have been reported. Tell your doctor or nurse right away if you have any new or worsening stomach pain or blood in your stool.
  • Treatment with TORISEL may be associated with a risk of kidney failure, sometimes fatal.
  • During treatment with TORISEL, wounds may not heal properly. Tell your doctor or nurse if you are recovering from surgery or have an unhealed wound. Tell your doctor or nurse if you plan to have surgery during treatment with TORISEL.
  • TORISEL may increase the risk of bleeding in the brain, which has, in some cases, been fatal. You are at increased risk if
    • You have a central nervous system tumor, such as a brain tumor
    • You are taking medicine to keep your blood from clotting
  • Some vaccines may be less effective when given during the course of treatment with TORISEL. You should avoid the use of live vaccines and close contact with people who have recently received live vaccines. Ask your doctor or nurse if you are eligible to receive a flu shot.
  • Both men and women should use a reliable form of birth control during treatment and for 3 months after the last dose of TORISEL. TORISEL can harm an unborn baby. Tell your doctor or nurse before beginning treatment if you are pregnant or thinking of becoming pregnant.
  • Elderly patients may be more likely to experience certain side effects including diarrhea, edema and pneumonia.
  • The most common side effects are
    • Rash
    • Weakness/fatigue
    • Mouth sores
    • Nausea
    • Swelling/fluid retention
    • Loss of appetite

Uninsured? Need help paying for Pfizer Medicines? Pfizer has programs that can help. Call 1-866-706-2400 or click here www.PfizerHelpfulAnswers.com

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