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 to see 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.

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 and factor concentrate 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 brands of factor concentrate you're currently using.

• Does the policy cover visits to my current physician or Hemophilia Treatment Center (HTC)?
• 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 factor or clinic visits, or any other type of medical services. Click here for more information on "Living with Lifetime Caps"
• Are factor concentrates covered by the insurance company? Certain companies may not pay for it, or have restrictions. Some will pay under the pharmacy benefit, so you may have a co-payment each time you receive factor. Others may cover factor under the medical benefit, meaning you may have to pay a deductible as well as a percentage of the overall cost. Click here for "Deciphering Your Insurance Plan."

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

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.

Contact your local HTC or factor distributor and work with them to appeal the denied claim. 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 (1-888-4ADVATE).

See the Online Resources section.

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.

Contact your homecare company, HTC, insurer or employer. A written "Authorization of Benefits" request may be required to get written documentation on lifetime caps. Baxter's Reimbursement Hotline (1-800-548-4448 or 1-888-4ADVATE) can also help you research this information.

Your homecare company or HTC can provide assistance in guiding you through this process. Baxter's Reimbursement Hotline (1-800-548-4448 or 1-888-4ADVATE) can assist you in researching and will work one-on-one with patients and homecare companies if necessary.

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 homecare company and insurer about converting factor 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 HTC or homecare company to explore the possibility of extending the lifetime cap via an exception for patients with chronic disorders. Either the insurance company or employer makes this determination.
• Work with your homecare company to reduce the cost of factor to your insurance company.

• 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 hemophilia 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.

Baxter's FACTOR ASSIST program can provide peace-of-mind regarding access to advanced hemophilia therapeutics.

• The FACTOR ASSIST Program can provide up to 100,000 units of ADVATE [Antihemophilic Factor (Recombinant), Plasma/Albumin-Free Method] in the event of an insurance lapse. You earn certificates while using Baxter therapeutics and can use them to obtain factor concentrate at no charge during a lapse of insurance.

You can easily determine this. Here's an example:

1. Amount of Deductible: $100
2. Percent Covered by Insurance: 80%
3. Percent Not Covered by Insurance: 20%
4. Out of Pocket Expense Limit: $500 (Amount you will have to pay before insurance covers 100% of the therapy)
5. Total Out-of-Pocket Costs: $600 (1 + 4)
6. Lifetime Cap Limit $1.5 million
7. Lifetime Cap Currently Used: $300,000
8. Estimate of Remaining Cap: $1.2 million
9. Estimation of Average Yearly Costs: $100,000
10. Years left on Cap: 12