AFLAC Cancer policy

Just read the contract. It will tell you exactly what your coverage is. It usually depends on the exact diagnosis and then, if eligible, any payments may be made on the type of treatment.

Probably what the representative meant is that the claim should be made in accordance with the qualifying language of the coverage. If the claim is ambiguous relative to the coverage, then you could have some clarifying to do. Most of these coverages are very specific. Get out the contract and read it. First look to see what the coverage is and then read the exclusions to see if any apply to you specifically.

Others on the board have gotten payments with less significant disease, but they were surgical patients and that may make a difference. Hopefully some with direct experience will chime in.

Most importantly, I hope the zytiga helps him for a very long time. Best wishes.

Here is the exact write up about the different therapys, And yes, a claim was filed when he was diagnosed and they did pay the radiation benefits when he did radiation. No payments have been made since then.

D. RADIATION AND CHEMOTHERAPY BENEFIT: AFLAC will pay the charges incurred up to $300 (three hundred dollars) per day for a covered person who receives one or more of the following cancer treatments for the purpose of modification or destruction of abnormal tissue:
1. Cytotoxic chemical substances and their administration in the treatment of cancer: a. Administration by medical personnel in a doctor’s office, clinic or Hospital. b. Self-injected medications or medications dispensed by a pump, will be limited to the cost of the drugs up to $300 (three hundred dollars) per prescription. c. Oral chemotherapy, regardless of where administered, will be limited to the cost of the drugs up to $300 (three hundred dollars) per prescription. Subject to a monthly maximum of $1,200 (one thousand two hundred dollars). 2. Radiation therapy; or 3. The insertion of interstitial or intracavitary application of radium or radioisotopes in sealed or non-sealed sources. (The Surgical/Anesthesia Benefit provides additional amounts payable for insertion and removal. Benefits will not be paid for each day the radium or radioisotope remains in the body.)
This benefit does not pay for laboratory tests, diagnostic X-rays, immunoglobulins, immunotherapy, colony-stimulating factors, therapeutic devices, simulation, dosimetry, treatment planning or other procedures related to these therapy treatments. No lifetime maximum.
This benefit is not payable on the same day that the Experimental Treatment Benefit is paid and is limited to $300 (three hundred dollars) per day.
E. EXPERIMENTAL TREATMENT BENEFIT: AFLAC will pay the charges incurred up to $300 (three hundred dollars) per day for a covered person who receives experimental cancer treatments for the purpose of modification or destruction of abnormal tissue. The treatments must be consistent with one or more National Cancer Institute sponsored protocols.
This benefit does not pay for laboratory tests, diagnostic X-rays, immunoglobulins, immunotherapy, colony-stimulating factors, and therapeutic devices or other procedures related to these therapy treatments. No lifetime maximum.

Debbie,

The medical definition of chemptherapy includes, but is not limited to, cytotoxic drugs. That the policy uses the heading Chemotherapy, then has the term cytoxic as the specific qualifier appears to me to be ambiguous given the medical definition and the broader use of drugs that are not cytotoxic, but do meet the definition of chemotherapy.

I have the same AFLAC policy and I was paid for the lupron shot and casodex as “Chemotherapy”. So I suppose that is why I got paid, that it was referred to as a chemo “type” drug, not ADT. I asked my rep for a 2nd level support person who I would fax my claims to directly. She would ensure I got paid for the various oncology bills I would send in. Good luck. -JR

Debbie,

I know this is a "pocket change" amount, but do remember that AFLAC pays $75 a year for 1 PSA test done. I forgot to send mine in, and they back paid three years. It is worth filling out the online form.

If you have something that they might pay for, submit it. Even if you don't think it will amount to much. Some is more than none. They may find more to pay, as I mentioned before. But you also create a chain that they will see for future claims.

Also, ask your oncologist how they are going to handle the Rx. I'm still sorting out my Medicare (to start in July), and my consultant has observed that how the meds are dispensed can throw them into Part B. I have UHC right now, and they required the Zytiga to come from OptumRx, so it was a "prescription". But Xtandi was different, as my Onco initially provided it from their office, therefore a "treatment". When we got to the longer term, it became a "prescription", and had to go back to OptumRx. Again, same thing, different handling. A single code can change everything.

A discussion with your docs may help. Mine is very agreeable to making my life easier.

The Zytiga has a monthly cost of around $10,000. It's not chemotherapy but a ADT drug like Lupron. There are programs that will help with the costs if you can not afford those co-payments..You can ask your doctor to get "pre-approval" before filling scripts these drugs..

An outfit called The Pan Foundation (there are other similar foundations all backed by the big drug companies) that sometimes will help you with the co-pays as long as you have some sort of health insurance. I don't know if they are still doing it..How old is Hubby ?

Fairwind,
Thank you. Husband is 67 and he does have medicare and United Health Plan F Supplemental. I will check on the Pan Foundation and will also ask his Oncologist next week if there are other organizations. We don't have much "income" ... but do have savings and own our home outright ... so we don't qualify for subsidies.

Those foundations that pay the co-pays have very liberal income requirements. Your house, car and savings don't usually count, just your annual income....Having both AFLAC and Medicare insurance is rather unusual..If AFLAC will cover the Zytiga, find out what, if any, co-pay you are responsible for..With Medicare, it's usually 20%...Drugs like Zytiga are filled by "Special Pharmacies" and are delivered to you by mail or UPS..Best of luck to you...

JNF ... very true and thank you for your insights. He has drug coverage with Symphonix Value RX right now. When I did the comparison (including Zytiga); they seemed the lowest total personal outlay for the year, somewhere around $11,000. I will be on the hunt for any foundations or other places to help with the cost. The Aflac looks like it will only pay $300 per prescription, so it probably won't be much ... but every little bit helps.

Thanks Fairwind .... to qualify for that program you must: Patient's income must fall below 400% of the Federal Poverty Guideline (FPG) with consideration of the Cost of Living Index (COLI) and the number in the household.

In 2018, the two family income must be below $16,460. Well ... his social security check is more than that and we do supplement it with our 401K. So, that one isn't going to work, thank you anyway ... maybe it will help some other folks on this forum.

My husbands next appointment is Tuesday. I'm sure Dr. Sartor's group might have some ideas and who knows, may have a trial they can assign him too .... we will see. Thanks again ... I do appreciate y'all.