If you have questions about your insurance, we’re here to help.
Understanding the Insurance Process
Insurance can seem complicated. But understanding the insurance process can help you plan for what’s next in your treatment path. Click the icons on the map below to learn more about the insurance process.
1. Decision to start treatment
Your healthcare team decides with you to begin treatment with RYSTIGGO.
2. Benefits investigation
During “benefits investigation,” your insurance provider determines if your medical plan has coverage for RYSTIGGO and its associated administrations. In addition, you will be notified if a prior authorization is required (please see step 3).
3. Beginning prior authorization
A “prior authorization” is the process of getting your medical plan to approve a service or prescription ahead of time to be sure that there will be coverage for a treatment. If required, prior authorization forms for your treatment will be sent from your insurance provider to your infusion provider. During this time, provider(s) with unknown numbers may contact you – be sure to answer your phone or check your voicemail.
4. Prior authorization approval
Good news! Your insurance provider has approved your prior authorization.
DETOUR: What if prior authorization is denied?
If prior authorization is denied, an appeal will be started by your healthcare provider on your behalf. Your prior authorization forms will be sent back to your provider to address any issues. You don’t need to do anything at this time – your Care Coordinator and healthcare provider will keep you updated.
5. Coordination of infusion and/or medication
Expect to receive a phone call from your healthcare provider(s) to schedule your first infusion and/or coordinate shipment of your medication if you are receiving infusion at home.
6. Financial responsibility
If you or your healthcare provider are acquiring RYSTIGGO through a specialty pharmacy, the specialty pharmacy will contact you for payment information for your cost share and to schedule shipment of drug and supplies. If your healthcare provider is purchasing RYSTIGGO, you will be asked for payment after you have received your infusion and a claim has been filed with your medical benefits.
7. Prepare for your appointment
Your Care Coordinator will help prepare you for your first infusion appointment. Be sure to check your “A Guide to Getting Started,” where you’ll find tips on appointment logistics, what to wear, and more to help you begin your treatment.
8. Start treatment
Your Care Coordinator will be available to help you throughout your treatment after you’ve started – whether that is to help you understand your ongoing treatment, fit your new treatment regimen into your life, or continue to advocate for yourself and communicate with your doctor. Remember, if your insurance changes or you have any questions during annual enrollment, your Care Coordinator is here to help.
There are many different types of insurance available today. Understanding these can help you have better conversations about finances, coverage, and insurance throughout your treatment journey.
This type of insurance can be purchased through a non-government (private) insurance provider. It may also be offered by an employer. These programs, costs, and coverage can vary widely depending on your specific plan and other factors.
Private health insurance can be purchased through the Exchange. The Exchange is your state’s price comparison website for various government-subsidized health insurance options. This type of insurance is usually purchased during an open enrollment period. This is the only time you can enroll in a plan or switch plans. However, certain life events may qualify you to enroll at other times.
Short-term insurance is temporary coverage for when you are between insurance plans. Short-term insurance plans are not provided by the government, but they can help pay for certain healthcare costs, including co-pays, coinsurance, and deductibles.
Medicare is a federally funded health insurance plan available for:
- People over 65 years old
- People under 65 years old who have certain disabilities
- People of all ages who have permanent kidney failure
People with Medicare can also purchase supplemental insurance. There are additional categories under which some people may qualify. Visit www.medicare.gov for more information or to sign up.
Medicaid is a type of insurance that is offered by the state in which you live, based on federal requirements. It is funded jointly by states and federal government. Medicaid may be available for:
- Low-income adults
- Children and pregnant women
- People over age 65
- People with disabilities
People with Medicare can also purchase supplemental insurance. There are additional categories under which some people may qualify. Visit www.medicare.gov for more information or to sign up.
If you do not have any insurance, you may qualify for help through UCB’s Patient Assistance Program. Get in touch with your ONWARD Care Coordinator to learn more.
GLOSSARY OF TERMS
Under the terms of your insurance plan, the period of time you receive coverage.
An analysis to determine if your insurance plan covers a service or prescription.
Your portion of the costs for a covered healthcare service. This is usually calculated as a percent of the service’s allowed amount.
What you pay at the time a service is rendered, including doctor’s visits and prescriptions. This is usually a flat fee, but the amount can vary depending on the service and your insurance plan.
The amount of money you pay before your plan begins to pay for a service.
A health insurance plan set up through the Health Insurance Marketplace®.
A process of proving how much money you earn through a job or government assistance.
Any healthcare service when you are admitted to a facility like a hospital.
Services or supplies that are required to diagnose or treat an illness, injury, disease, condition, or symptoms.
A specified amount that Medicare will pay for a healthcare service.
A type of health insurance purchased from a private company that pays healthcare costs Medicare does not.
The amount of insurance covered a person must have under the Affordable Care Act.
The period of time during which an individual can sign up for a health insurance plan or change their insurance plan.
Services received by healthcare providers who are not in contract with your insurance plan.
Any healthcare services that do not require a person to be admitted to a hospital or treatment facility.
A specified amount of money that you (or your employer) pay, out of pocket, for a health insurance plan. A premium can be paid monthly, quarterly, or yearly.
An approval obtained from your health plan for a service or prescription. This ensures your service or prescription will be covered by your insurance.
Through ONWARD, you have a dedicated Care Coordinator who can help you understand insurance and your coverage.
*ONWARD Care Coordinators do not provide medical advice and will refer you to your healthcare professional for any questions related to your treatment plan.
