How to navigate RRMM insurance and treatment costs
If you have multiple myeloma that has relapsed or is refractory, meaning it’s resistant to medications or other therapies, then you know how challenging it can be to navigate not just the cancer itself, but also the cost of treatment. This may be especially true if you’re pursuing alternative or advanced therapies for your relapsed/refractory multiple myeloma (RRMM).
However, despite the challenges, there are resources and strategies you can use to help you navigate RRMM insurance coverage and treatment costs. Keep reading for tips on getting financial assistance for multiple myeloma care, managing RRMM insurance changes, and more.
Familiarize yourself with your insurance plan
It’s also crucial to understand your RRMM insurance coverage, including your out-of-pocket costs.
Before making any decisions, get a copy of your insurance policy and read through it. Make note of any questions you have or areas where you’re unclear.
Pay close attention to information about:
- Medical necessity: Look for an explanation of how your insurer defines “medical necessity” for high-cost medications used to treat rare diseases like multiple myeloma. Coverage may hinge on whether your insurer deems a medication medically necessary for RRMM. The stronger the documentation, the better your chances of approval.
- Off-label drug use: Insurers often regard medication that’s being used off-label, or to treat a condition for which it’s not approved, differently from a drug that’s being prescribed according to regulatory guidelines. If your doctor has prescribed an off-label medication, it may not be covered by insurance. Alternatively, prior authorization may be needed.
Understand prior authorizations and appeals
Prior authorization means the insurer requires your doctor’s office to get approval before you start treatment. If the request is approved, you can proceed with the medication or therapy. If it’s denied, don’t assume the decision is final. Ask why it was denied, then appeal. Many oncology appeals are eventually approved.
Start by asking your insurer for an appeals template to format your request correctly. Next, request a clear document checklist so you know exactly what supporting evidence you need to gather. Your doctor will likely need to write a detailed Letter of Medical Necessity for RRMM outlining your unique treatment history and why this medication is being prescribed.
Make use of policy specialists
In many cases, insurers will have a specialist that you can contact directly with questions about your policy. It’s worth calling your insurer to see if there’s a specialist who can offer personalized support. The company may also be able to provide a contact who specializes in complex oncology claims.
Accessing financial assistance
RRMM treatment costs can be very high. Medication costs can be affected by things such as:
- White-bagging versus brown-bagging: White-bagging means the pharmacy sends the medication directly to your doctor, who administers it to you. Brown-bagging means the medication is given directly to you by the pharmacy. The method matters because manufacturer copay cards and assistance grants may have different rules depending on the route.
- Medical benefits versus pharmacy benefits: Your insurance provider can also tell you whether a particular medication will be covered under your medical benefit or your pharmacy benefit. Each benefit typically has separate copays and deductibles.
There are a number of financial resources you may be able to pursue to help you pay for medications.
Ask your healthcare team for help
Remember that your doctor is there to help treat you, including helping you overcome any barriers to treatment, such as cost. With that in mind, it’s important to talk with your doctor about any financial barriers or concerns you may have about a treatment’s costs.
Your healthcare team can refer you to your hospital’s social worker, who has specialized training and access to resources to help you. The social worker may be able to get you set up with a sliding-scale payment plan if your medication is administered to you at the hospital, or point you toward other financial assistance for people with multiple myeloma.
Specialty pharmacy liaisons
Specialty pharmacy liaisons connect you, your doctor, and the pharmacy. These individuals may be able to help you access high-cost medications via coupons, insurance, or financial assistance programs.
Manufacturer support programs
Some drug manufacturers offer RRMM patient support programs. These programs may offer coupons and vouchers, especially if you’re experiencing a delay or gap in coverage while managing RRMM insurance changes. Check the manufacturer’s site for these resources.
Nonprofit grants
Nonprofits such as the International Myeloma Foundation, the Patient Advocate Foundation, and other organizations offer copay assistance grants and other types of financial assistance to help pay out-of-pocket RRMM treatment costs.
Understanding Medicare cost protections
If you have Medicare Part D, it’s important to understand your out-of-pocket cost for RRMM medications. Plan premiums and deductibles may vary, but once you meet your deductible, you’ll pay a set coinsurance percentage until you reach your out-of-pocket cap for the year.
You can check the current out-of-pocket cap at Medicare.gov. Once you hit the cap for the year, you’re automatically granted catastrophic coverage. That means you won’t have to pay anything for covered medications for the rest of the year.
If you’re enrolled in a Medicare Part D plan or another Medicare plan with drug coverage, you have the option to enroll in the Medicare Prescription Payment Plan. This plan can help you manage your monthly drug costs by smoothing them out evenly throughout the year. While it doesn’t save you money, it may be helpful when budgeting since your costs will be more predictable.
Medicare Advantage versus Medigap for cancer
Medicare Advantage and Medigap are two different Medicare coverage options.
Medicare Advantage (Medicare Part C) is a private insurance policy that’s an alternative to Medicare. If you’re enrolled in Medicare Advantage, you have an out-of-pocket cap. You’ll pay copays or coinsurance until you reach your cap. After that, your plan will pay all covered medical expenses for the rest of the year.
Medigap is a supplement to original Medicare. It’s designed to help you pay out-of-pocket costs like copays, coinsurance, and deductibles.
Medicare Advantage typically has lower monthly premiums compared with Medigap. However, Medigap often offers lower out-of-pocket costs overall.
With Medigap, you can see any doctor in the U.S. that accepts Medicare. With Medicare Advantage, however, you may be restricted to only certain in-network doctors. This is important to keep in mind when deciding between the two plans.
Essential next steps for patients
It can be overwhelming to navigate the complex world of insurance and high-cost medications, especially when you’re trying to focus on your overall well-being. Know that you’re not alone, and there are resources available to help you.
Follow this simple checklist to get started:
- Create a dedicated financial binder for important information and documents related to your RRMM insurance coverage and treatment costs.
- Read and understand your insurance policy.
- Ask questions of your insurance provider, and get contact information for a policy specialist who’s well-versed in complex oncology claims.
- Let your doctor know if you anticipate cost may be a barrier to treatment, and ask your team to connect you with the hospital’s social worker.
- Look into RRMM patient support programs and grants.
- Understand your Medicare coverage, if you have it.
Rare Cancer News is strictly a news and information website about the disease. It does not provide medical advice, diagnosis, or treatment. This content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read on this website.
