From the very beginning of your journey, you are encouraged to focus on yourself and your treatment while fighting early-stage, estrogen receptor positive (ER+) breast cancer. But, the financial burden from out-of-pocket medical expenses can build up and distract you from this focus.
You didn’t budget for cancer. No one budgets for cancer.
For example, anti-estrogen therapy is often used to treat breast cancers that test positive for estrogen receptor, whereas other types of breast cancer may be treated with anti-HER2 therapy based on identifying human epidermal growth factor receptor 2 (HER2) gene amplification or over-expression (which results in too many copies of HER2 that causes abnormal cell growth) In addition, new genomic tests help physicians and patients understand their individual risk of relapse and likelihood of benefiting from specific treatments.
Cost of Cancer
Expenses may come from all areas: from your diagnosis through your initial and long-term treatments, including:
- Doctor, clinic and hospital appointments
- Laboratory tests
- Surgical procedures
- Adjuvant treatments such as chemotherapy and anti-estrogen therapy
- Secondary medicine and/or side effect therapy and prescription drug treatments
- Peripheral services such as home health visits or counseling
- Time away from work for you and your support team
Prioritizing cost coverage and potential out-of-pocket expenses for these services reflects the personal experience of each patient. Many of these services influence other parts of your treatment and care experience. For instance, laboratory tests influence many points along your treatment timeline, such as confirming your ER status and your treatment plan designed around an early stage ER+ breast cancer diagnosis.
Genomic Tests for Patients with Breast Cancer
Newer molecular diagnostic tests, such as Oncotype Dx and Breast Cancer Index, take it a step further by providing information to help you and your healthcare team decide on treatment regimens. These prognostic and predictive tests provide information on your risk of distant recurrence and likelihood of benefit from chemotherapy soon after diagnosis (Oncotype Dx) and risk of late distant recurrence and likelihood of benefit from anti-estrogen therapy beyond five years (Breast Cancer Index).
Results from these tests are considered along with your other medical factors and provide personalized information specific to the tumor tested to help navigate treatment options. Thousands of women and their physicians have used these tests to provide personalized information for shared decision making.
They are important in your treatment and care experience, so how do you pay for the newer breast cancer molecular diagnostic tests? Let’s take a look.
Patient Advocate Programs
Some molecular diagnostic companies have programs that will provide both billing education and assistance for a patient. These services reduce the complexity of paying for these important tests. A few of the tests that have patient programs include*:
- Breast Cancer Index – Patient Advocate Team
- Oncotype DX – Genomic Access Program
- MammaPrint – Patient Advocates
The Centers for Medicare & Medicaid Services provides a comprehensive review of the Medicare program on medicare.gov. Medicare considers many of the new molecular diagnostic tests as a medical necessity under specific criteria (each test will have differing criteria based on what information the test provides). If you meet these criteria, the test will be fully covered by Medicare.
Medicare determines payments for items or services at the national level (National Coverage Determination or NCD) and local or regional level (Local Coverage Determination or LCD). It is important to work with your healthcare team and the companies’ advocacy teams to identify where you fit in the Medicare program. Some molecular diagnostic tests provide their NCD or LCD criteria such as Breast Cancer Index.
Commercial Insurance Coverage
The growing familiarity of newer molecular diagnostic tests for both oncologists (treatment decisions) and insurance plans (potential cost savings) has increased the number of commercial insurance plans covering these tests.
Each insurance plan will have specific criteria that will determine coverage of molecular diagnostic tests as a medical necessity. Be sure to work with your insurance company and the test advocacy team to find the best path for covering the cost of your test.
Out-of-pocket expenses will depend on your insurance plan (benefits, deductible, co-insurance, out-of-pocket max) or lack of insurance coverage. Be sure to check with the test company about their assistance programs.
Patient Assistance Programs
If a patient is deemed to pay for a molecular diagnostic test through Medicare or commercial insurance, there is still a chance to reduce the out-of-pocket expense burden through the tests company patient assistance programs. Some of these companies provide assistance for underinsured or uninsured patients:
- Breast Cancer Index – Billing Information Sheet for Patients
- Oncotype DX – Paying for the Oncotype DX Test
- MammaPrint – Insurance Coverage
*Questions about interpreting the test results or your specific treatment plan should be addressed by your physician.
Stay tuned for our next topic in the coming weeks.