Health Plans’ Coverage Of Some Drugs Can Be A Source Of Consumer Confusion

(Photo by Chris Hondros/Getty Images)
Cancer patient Caroline Whitley gets chemotherapy treatment at the Cape Fear Valley Cancer Center in Fayetteville, N.C. in 2010. (Photo by Chris Hondros/Getty Images)

Patients getting chemotherapy or other complex medications may have a sudden panic when shopping for health insurance: Their drugs often don’t appear to be covered.

“People think, ‘Jeez, what do I do now?’” said Anna Howard, policy principal at the American Cancer Society Cancer Action Network.

Despite advice to shop around before selecting a plan, consumers may find that getting answers about drug coverage can be an exercise in frustration, despite a federal health law requirement that insurers provide lists of the prescription medications included in their plans.

That’s because many treatments — particularly intravenous treatments like those used in cancer, hemophilia or multiple sclerosis — are covered under a separate part of an insurance plan, not the pharmacy benefit. And details of that medical-benefit drug coverage can be hard or impossible to find online. But the information is important to know because the drugs tend to be costly, so if they’re not covered, patients might have to pay out of pocket, switch to different treatments or appeal to the plan.

It’s fairly straightforward to check online formularies for pharmacy-covered medications, such as cholesterol treatments or blood pressure medications.

But checking for medical-benefit drugs is much more complicated for consumers and can involve clicking through layers of websites. Even finding out if a drug is part of the medical benefit coverage instead of the pharmacy formulary isn’t easy.

“I haven’t been able to find that and I do this for a living,” said Katie Verb, associate director of policy and government relations at the Hemophilia Federation of America.

Medical-benefit drugs are mainly complex treatments that are infused or injected in a medical setting, such as a doctor’s office or chemotherapy clinic. In contrast, pharmacy-side drugs are generally pills or are self-administered injections.

In doing a search, consumers might need to know to which “therapeutic class” their drugs belong, or possibly their generic names. Even then, the information might not be available online. Insurers’ call lines don’t always have information about medical benefit drug coverage, either.

Insurers admit the difficulty in finding the information about intravenous drugs covered under the medical benefit.

“It requires legwork,” said Don Liss, a physician and vice president of clinical programs at Independence Blue Cross in Pennsylvania. “These calls get transferred to me on occasion.”

What kind of legwork?

This reporter tried to find the answer to a seemingly simple question posed by a friend: Is the chemotherapy drug she will soon need — Abraxane — covered by any of the insurance plans in her area?

Using directories available through the federal government marketplace,, one could quickly locate in-network doctors, hospitals and labs for insurance plans in her area. Not so with Abraxane, approved in 2005 to treat metastatic breast cancer.

Typing it into the drug finder for one major insurer — CareFirst BlueCross Blue Shield in Virginia — yielded no information. Nor did it appear on an initial search for covered drugs in plans from Innovation Health, a partnership between Aetna and the Inova Health System. The link to the drug lists on for plans offered by UnitedHealth Group didn’t work at all, showing only “no records found.”

Such broken links and missing information were noted in two recent studies by the Cancer Action Network, which concluded that simply relying on insurers’ websites or the online marketplace isn’t enough. The group, which studied health plans sold through federal and state exchanges in six states, also found that coverage for intravenous medications was unclear in most plans.

Verb and other advocates say information about medical-benefit drugs should also be posted, pointing to a few states, including West Virginia and Texas, with new laws requiring insurers to provide “information sufficient to determine whether a specific drug is covered when furnished by a physician or clinic.”

One difficulty with providing lists of medical benefit treatments on marketplace websites, insurers say, is that there are nuances with many treatments. It isn’t just a matter of yes or no.

Some oncology drugs, for example, are covered for certain types of cancer, but not others, Liss at Independence said.

He noted that on Independence’s website, consumers can reach a tab called “medical policies,” then type in a drug name to find coverage policies for various treatments under the medical benefit. Doing so for Abraxane shows it is a covered medication for metastatic breast cancer and some other cancers.

In addition to searching websites for “medical policies,” what are other steps consumers can take to find if their medications are covered?

Try searching by type of drug.

When an initial search of the “drug finder” function didn’t come up with Abraxane, the Innovation Health site suggested searching by “therapeutic class.” But there are many classes and subtypes, some with names like “hedgehog pathway inhibitors” or “nitrogen mustards.” Consumers may need to consult their physicians or the drug companies to find out.

Ask your doctor or billing office.

Oncologists generally know which drugs are covered by local insurers — and which are more problematic. Billing office managers are also familiar with coverage, so ask, and be specific about the insurer and the plan under consideration. Many insurers cover all treatments recommended by the National Comprehensive Cancer Network, a nonprofit alliance of 26 major cancer centers.

Check the generic name.

Some drugs are listed by generic name. Abraxane, for example, is the brand name for a type of paclitaxel. Entering that generic name on Innovation’s drug finder located it on the formulary. Still, that doesn’t work every time. CareFirst’s website didn’t list paclitaxel either.

Call the plan.

Have the exact name of the plan you are considering, as formularies and policies can vary, even within the same insurer. Federal regulations say information must be made available to prospective customers as well as existing ones. But sales reps may not have information about drugs covered under the medical benefit, rather than the pharmacy side.

CareFirst’s member services and sales staff found Abraxane was covered under the medical benefit on a 2015 formulary, but representatives said the 2016 list wasn’t available. Eventually, CareFirst’s public relations representative said the 2015 specialty list won’t change for 2016, so the drug is covered.

Categories: Insurance, Syndicate

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