Health insurance can feel like an ambiguous topic, but let’s navigate it together! Believe it or not, health insurance can be broken down into two main categories: commercial and public.

What is public health insurance?

Public health insurance includes coverage provided by government-run programs such as Medicare and Medicaid. These plans are typically offered to and utilized by low-income individuals or families, the elderly, and other individuals that qualify for special subsidies. Medicare is a federal social insurance program for seniors (generally persons aged 65 and over), and certain disabled individuals. Medicaid covers millions of low-income children and their families. It is funded jointly by the federal government and states but is administered at the state level. Public health insurance is more affordable for its users, but typically has less flexibility and a limited selection of providers.

What is commercial or private health insurance?

Any type of health insurance plan that is not provided or maintained by a government-run program is considered commercial or private health insurance. These types of insurance plans are often much more expensive than public health insurance, but they are significantly more flexible, giving the policyholders a wider selection of medical providers.

What does my insurance plan cover?

If you are not sure what your insurance plan covers, there are a couple of different ways that you can find out. One option is to call the member services number located on the back of your insurance card. They will ask for the name of the policyholder, plan number, and group number in order to pull up all of the correct information on their end. Notify your insurance provider of the diagnosis made by your physician so they can go over their specific formulary of drugs. An alternative option is to log in through your insurance portal and search the medication formulary related to your plan to determine if a particular drug is covered. These same steps can also be taken to determine if a physician or clinic is in-network.

Why does it matter if my insurance “covers” something?

Anything not covered by your policy could potentially result in out-of-pocket costs, meaning the patient is responsible for paying for anything extra that the insurance company will not cover. Knowing what your insurance does and does not cover is important in knowing what you will be financially responsible for. The thought of paying out-of-pocket for your treatment can be intimidating, so what do you do if you are uninsured or underinsured and require infusion therapy? There are a few options available to assist patients with out-of-pocket costs:

Manufacturer Patient Assistance Programs – If uninsured, pharmaceutical manufacturers may sponsor patient assistance programs (PAPs) that will provide the drug for free or financial assistance to help cover the drug's cost. These programs typically cover only the amount of the drug itself, and the patient would be responsible for the additional cost of supplies and administration fees. Patients are qualified for these programs based on financial need. NeedyMeds is an excellent online resource that provides patients with access to PAPs available by drug name. If a medicine does not appear in their database, then you should check with the drug manufacturer’s website.

Copay Cards – If commercially insured but still requiring financial assistance, copay cards are available through certain manufacturers to assist with additional out-of-pocket costs for the drug itself. Depending on the manufacturer’s stipulations, sometimes these cards can also help cover administration costs. This card acts as a “secondary payer” in addition to the patient’s primary insurance. A patient can enroll in a copay program online, by phone, or by having their doctor provide the enrollment information with their prescription to be sent to the drug manufacturer directly.

Outside Nonprofit Grants – If publicly or privately insured and requiring additional financial assistance, multiple nonprofit organization grants are available to help patients cover drug copay, administration, supplies, insurance premiums, and more. Some organizations that provide funding support to patients include the PAN Foundation, Good Days, and the HealthWell Foundation. Most of these grants will require proof of financial need in the form of pay stubs, W2, etc..

How many times have you wished health care wasn’t so complicated? Learn more about Paragon's focus on making your life a little bit easier. As a specialty infusion services provider, Paragon Healthcare treats 300+ diseases and disorders through injectable and infusible therapies. Currently, Paragon serves 30,000+ patients annually and projects to treat more than 100,000 patients annually by 2025.