Empire
Plan Chemotherapy
Benefits
As if having cancer isn’t
bad enough, several Empire Plan enrollees have learned too late that their
out-of-pocket expenses for chemotherapy will be much higher than expected.
These enrollees weren’t aware that the benefits for chemotherapy differ
significantly depending on the provider they use.
Usually a patient has
chemotherapy as an outpatient, in one of the following locations:
- In
a physician’s office
- In
the outpatient department of a hospital
A hospital-affiliated extension clinic may be located in the hospital, on the same grounds as the hospital but in a separate building, or at a different site than the hospital. Chemotherapy performed in the outpatient department of a hospital or at a hospital-affiliated extension clinic is covered by Empire Blue Cross and Blue Shield under the hospital portion of the Empire Plan.
The Problem
If you receive outpatient
chemotherapy in a non-par physician’s office, you will be reimbursed under the
Basic Medical Program subject to the annual deductible ($309 in 2005) and
coinsurance. After you satisfy the deductible, the Plan will reimburse you
for 80 percent of the reasonable and customary (R&C) charges, or
actual billed charges, whichever is less. The reimbursement increases to
100 percent once the combined coinsurance amount for you and your covered
dependents exceeds $1,486 (2005). You must pay for any amount that exceeds the
R&C Charge.
You should know that the
R&C Charge used to reimburse enrollees for chemotherapy drugs
administered in a non-par physician’s office may be much less than the billed amount. By the time
these claims are processed and the enrollee receives an Explanation of
Benefits statement, s/he may have incurred thousands of dollars in
expenses that will not be reimbursed by the Empire Plan.
A Solution
If you receive
chemotherapy in a non-par physician’s office, there is a way to protect yourself from financial
hardship. Instead of having a non-par provider dispense your chemotherapy
drugs, buy them from a participating retail pharmacy or through the
mail-order pharmacy. When buying the drugs from a par pharmacy, you will
only have to pay a small copayment. You then bring the drug(s) with you to
the physician’s office.
To ensure you receive the maximum benefits available for outpatient chemotherapy, it’s important that you understand how the Plan works. Your choice of provider will determine how much you have to pay out-of-pocket (see chart). If you have questions about what the Plan will pay if you receive outpatient chemotherapy in a setting other than the outpatient department of a hospital or hospital-affiliated extension clinic, call UHC at 1-877-7NYSHIP.
(Updated 9/27/05)