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The Drug Deal: Insurance and Access to Prescription Medications

The Drug Deal: Insurance and Access to Prescription Medications

With the right tools and information, accessing the right prescription medication for your cancer diagnosis doesn’t have to be complicated.

One of the most daunting challenges a cancer warrior faces is paying for what are often very expensive medications. Medicare and Medicaid plans include prescription drug coverage, and the Affordable Care Act mandates that most private insurance plans also provide prescription drug benefits. However, insurance policies with prescription drug coverage have a list of approved medications called a “formulary,” greatly affecting the cost and approval of an individual prescription.

The cost of a medication depends on whether a prescription is within the insurance plan’s formulary as well as which tier it is on. These details vary from plan to plan; therefore, your physician may not know how the prescription is covered, if at all. If you notice that a medication is not within your plan’s formulary or is cost-prohibitive, you should discuss your options with your physician. They may be able to prescribe an alternative medication that is more affordable.

Some medications may require a “prior authorization” before insurance will assist in payment. In this case, your physician will need to contact the insurance company to obtain permission to prescribe the drug. It is recommended that you review your insurance policy for information on prior authorization requirements.

Another possible hurdle may be insurance companies requiring patients to undergo “step therapy” before the approval of certain medications. Medications that are new, expensive, or brand-name may not be covered until an inexpensive, alternative medicine is tried first. The patient will be required to demonstrate that this alternative medication is not effectively treating their symptoms or illness in order for the insurance company to authorize a higher-cost prescription. Keep in mind that the denial of coverage by insurance is not the final word on whether your treatment will be covered. Patients have the right to appeal the decision of an insurance company. Your physician can write a letter of appeal detailing why the medication in question is necessary for your treatment.

If a necessary prescription is still too expensive, there are ways to obtain discounted or even free medication. For example, your physician may be able to provide samples of the medication to you. Pharmaceutical companies manufacturing the drug may provide coupons and pharmacies may have discount cards to help patients pay for their prescriptions. To learn more about these options, please contact the Cancer Legal Resource Center or your insurance carrier.

Clinical trials may provide another alternative for receiving treatment. Eligibility for these trials can be confusing, but your doctor can assist in explaining requirements and whether participating in a study is right for you. If you are interested in clinical trials or other experimental treatments, you should discuss with your physician what trials are available based on your condition and prior response to other treatments.

If you’ve determined that a trial is right for you and need additional assistance in finding one, there are organizations dedicated to helping patients navigate the clinical trial process and matching them with potential studies for which they may be eligible. Mailing lists alerting members to new open trials are also available. Some resources include:

  • The American Cancer Society: assists in explaining the ins and outs of clinical trials to help you decide whether this option is right for you. Visit www.cancer.org/clinicaltrials or call 1-800-227-2345 for more information.
  • EmergingMed: provides free, confidential matching and referral services at www.emergingmed.com or by calling (877) 601-8601.

Checking clinical trial lists from various organizations is another option. These contain names and descriptions of studies, patient eligibility criteria and contact information. The following are sources for commonly used lists:

See Also

  • National Cancer Institute (NCI) sponsors most government-funded cancer clinical trials and maintains a list of active studies with open enrollment, including some privately funded studies. Find the list on their website at www.cancer.gov/clinicaltrials or by calling 1-800-4-CANCER (1-800-422-6237).
  • Center Watch is a publishing and information services company that keeps a list of both industry-sponsored and government-funded clinical trials for cancer and other diseases.

If you are interested in research on a particular experimental treatment and know which company is developing it, some private companies such as pharmaceutical or biotechnology firms may list sponsored studies on their websites or provide this information by phone. These companies may also offer matching systems for studies they sponsor.


Editor’s Note: Learning your rights and how to enforce them can help protect yourself in the present and prevent legal problems in the future. For more tips or answers to cancer-related legal questions, contact the Cancer Legal Resource Center at 866-843-2572 or visit cancerlegalresources.org.

Disclaimer: Through this article, the author is not engaged in rendering any legal or professional services by its publication or distribution. It is not intended to be legal advice or establish an attorney-client relationship.


Shelly Rosenfeld is Co-Director of the Cancer Legal Resource Center (CLRC), a national program of Disability Rights Legal Center in Los Angeles, California. CLRC provides free education and resources on cancer-related legal questions to cancer survivors, caregivers, and health care professionals.

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