ITP Education Kit

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educational patient kit

ITP Juego Educativo

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y WinRho cuando usted ordena el ITP Juego Educativo de Recurso

Common Insurance Questions


General Insurance

Living with Lifetime Caps

General Insurance

Q: When can I make changes to my insurance coverage?

Employee-based insurance plans allow you to make changes during the annual open-enrollment period. Many times these decisions need to be made at the end of the year, since many policies become effective at the beginning of the next year. Check with your employer when your open enrollment period is and the options offered. You should also check to see whether your current plan has changed or if your employer is offering new types of plans.

Q: What difference does it make which type of coverage I choose?

You may have a choice between a traditional fee-for-service policy or more restrictive HMO, POS, or PPO coverage. Your choice depends on how much freedom you want in selecting your doctor or the cost savings you’ll obtain by having a more limited choice. Your choice may depend on whether your physician is part of the plan. It is also important to find out if the new plan covers the brand of therapeutic you’re currently using.

Q: What questions should I ask when I’m looking for insurance coverage?

  • Are visits to your current physician covered?
  • Are there any hospitals not included on the policy? Some policies restrict the number of hospitals at which you can receive care, so it is very important that you research this restriction thoroughly before making an insurance selection.
  • Does the policy have a lifetime maximum on benefits? This represents the maximum costs the policy will cover during your lifetime. If exceeded, your insurance may no longer pay for doctor visits, therapeutics, or any other type of medical services. Click here for more information “Living with Lifetime Caps”
  • Is WinRho® SDF reimbursed by the insurance company? Certain policies may not pay for or have restrictions on WinRho® SDF. Some policies will pay for WinRho® SDF under the pharmacy benefit, so you are only obligated to pay a co-payment each time you receive WinRho® SDF. Other policies may cover WinRho® SDF under the major medical (hospital) benefit. In this case, you may have to pay a deductible as well as a percentage of the overall cost.

Q: How can I find out if a specific treatment was covered?

After you or your doctor send a claim to your insurance provider, you will receive an Explanation of Benefits (EOB). The EOB summarizes and explains the amounts approved and paid to healthcare providers, and also details why certain services were not covered or paid for.

Q: Can I be covered by more than one insurance plan?

Yes. Other family members may have insurance plans offering additional coverage for which you may be eligible. Some health-care providers will bill a secondary insurer, while others will not. Look at the Explanation of Benefits to determine whether the other insurer has been billed, and if it has not, call the primary insurance plan and update them.

Q: What can I do if I am denied coverage for my treatment?

If your therapy is denied coverage, contact your local physician or WinRho® SDF distributor. Request reconsideration and possibly file a formal appeal. Make sure you truly understand the reason for the denial. If you do not feel the denial is justified, contact your insurer’s Patient Services Coordinator or Baxter’s Reimbursement Hotline (1-800-4WINRHO).

Q: What online resources are available for insurance information?

See the Online Resources section.

Q: What else should I remember when dealing with insurance?

You are your best advocate for insurance coverage. This is why you must fully understand your insurance policy and the resources available to assist you.

Living with Lifetime Caps

Q: How can I find out if I have a lifetime cap and if I do, what the total is?

Contact your insurer or employer. A written “Authorization of Benefits” request may be required to get written documentation on lifetime caps. Baxter’s Reimbursement Hotline (1-800-4WINRHO) can also help you research this information.

Q: Where can I find help seeking alternatives if I reach a lifetime cap?

Baxter’s Reimbursement Hotline (1-800-4WINRHO) can assist you in researching and will work one-on-one with patients and healthcare professionals if necessary.

Q: What are some ways I can seek alternative insurance before reaching my cap?

Following are some ideas for alternative insurance:

  • Change insurance during your open enrollment period. Many times lifetime caps start over with new insurance.
  • Ask your insurer about converting reimbursement from the medical benefit to the pharmacy benefit. Drugs dispensed and reimbursed through the pharmacy benefit do not impact lifetime caps.
  • Work with your insurance company or employer to explore the possibility of extending the lifetime cap via an exception for patients with chronic disorders.

Q: What happens if I exceed my insurance policy’s lifetime cap?

  • Research the possibility of switching to your spouse’s insurance.
  • Utilize premium assistance programs such as Patient Services Inc. (PSI). If you qualify, the program will pay for an individual insurance policy for you.
  • Applying for Medicaid will provide access to therapeutics, especially for children. You must meet your state’s financial criteria to qualify.
  • Check to see if you qualify for Medicare/Disability.
  • Research the availability of state high-risk pools. These pools provide assistance to patients who do not qualify for insurance but have the ability to pay premiums. Click here to check if your state has a high-risk pool.

Q: How can I determine the number of years left on my lifetime cap?

You can easily determine this. Here’s an example:
Amount of Deductible: $100
Percent Covered by Insurance: 80%
Percent Not Covered by Insurance: 20%
Out of Pocket Expense Limit: $500 (Amount you will have to pay before insurance covers 100% of therapy)
Total Out-of-Pocket Costs: $600 (1 + 4)
Lifetime Cap Limit $1.5 million
Lifetime Cap Currently Used: $300,000
Estimate of Remaining Cap: $1.2 million
Estimation of Average Yearly Costs: $100,000

Years left on Cap: 12