Understanding Insurance

Questions about insurance coverage?
We can help.

Insurance companies often have special requirements that must be met before they agree to cover your medication. For instance, they may require you to try other medications before trying CIMZIA. That’s where CIMplicity® can help.* We can work with your doctor’s office to verify whether CIMZIA is covered under your insurance plan. This is called a benefits investigation. We can also help your doctor’s office with paperwork the insurance company may require before starting CIMZIA, or prior authorization.

Knowing all the ins and outs of insurance can be a little confusing at times. Learn more about the different types of insurance coverage below or check out our glossary of terms to get a better idea about certain terms and phrases that are commonly used when talking about insurance.

The types of insurance, explained

Private (commercial) insurance

This type of insurance is often offered by an employer, or you can buy insurance through a private (non-government) insurance provider. Visit HealthCare.gov for more information about coverage available in your state. Programs and costs vary, especially in terms of coverage, co-pays, and deductibles.

About the Health Insurance Marketplace (the Exchange)

The Health Insurance Marketplace, also known as the Exchange, was created through the Affordable Care Act (ACA), commonly called Obamacare. The Exchange is your state’s price comparison website for government-supported (subsidized) health insurance.

Each year, there is an open enrollment period. This is the only time you can enroll in a plan, switch plans, or apply for cost assistance. However, certain life events may qualify you for a special enrollment period.

For general insurance help, call 1-866-4-CIMZIA (1-866-424-6942), option 2.

Short-term insurance

This is temporary health insurance when you are in between coverage. It is not considered minimum essential coverage.

Supplemental insurance

Supplemental insurance works as an addition to your major medical health insurance plan, and it is sold by private companies only. It is not provided by the government regardless of your income level. These plans can help pay some of the healthcare costs that your health insurance plan does not cover, like co-pays, coinsurance, and deductibles.

Medicare

Medicare is a federally funded health insurance program for:

  • People age 65 or older
  • People younger than 65 with certain disabilities
  • People of all ages with end-stage renal disease (permanent kidney failure requiring dialysis or a kidney transplant)

If you qualify for Medicare but need additional support to cover out-of-pocket expenses, there are supplemental insurance options that may help. For Medicare enrollees, there are certain rules that you must follow in order to get supplemental insurance. Please visit www.medicare.gov for more detailed information on Medicare policies.

Please note: Savings cards for prescription assistance cannot be used with Medicare.

Medicaid

Medicaid is a type of insurance that is provided by the state where you live. It is specifically designed to provide health coverage for some:

  • Low-income adults
  • Children and pregnant women
  • People who qualify under an eligible category
  • People age 65 and older
  • Individuals with disabilities

Visit Medicaid.gov for more information, to sign up, and to see what kind of coverage you may be able to receive. Medicaid is provided by states based on federal requirements. It is jointly funded by states and the federal government and is available to individuals who earn less than a set amount of income each year.

For more information and to see the full Federal Poverty Level table, please visit http://obamacarefacts.com/federal-poverty-level/.

For general insurance help, call 1-866-4-CIMZIA (1-866-424-6942), option 2.

No insurance/Uninsured

If you are uninsured, other financial assistance may be available through UCB’s Patient Assistance Program. Call 1-866-395-8366 (option 4) and we may be able to put you in touch with an independent organization that can help.

Glossary / Key terms to know

Benefit period: The amount of time you are covered under the terms of your insurance plan.

Benefits investigation: An analysis, usually done by a doctor’s office, to see if a service or prescription is covered under your insurance plan (also known as benefits verification).

CIMplicity® Covered™: This program provided by UCB offers eligible commercially insured patients whose prescription is initially denied or delayed by insurance a chance to receive free treatment for up to 2 years while we work to obtain insurance approval, whichever comes first. Additional restrictions apply. To find out if you are eligible, call 1-844-277-6853.

CIMplicity (Co-pay) Savings Program: Provided by UCB for treatment with CIMZIA, this Program offers eligible commercially insured patients assistance with paying the co-pay portion of a particular treatment (similar to a co-pay card).‡

Coinsurance: Your share of the cost of a covered healthcare service, usually a percentage of the allowed amount for the service (for example, 10%). You pay coinsurance after you’ve met your deductible.

Co-pay: A flat fee you pay for certain covered services such as a doctor’s visit or prescriptions. The amount can vary depending on the type of insurance you have or the service being performed.

Deductible: A flat dollar amount you must pay out of your own pocket before your plan begins to pay for covered services.

Exchange plan: The insurance you set up through the Healthcare Insurance Marketplace. Income verification: Proof of how much money you earn from your job or receive through government assistance.

Inpatient: Healthcare treatment you receive when you’re admitted to a healthcare facility like a hospital or nursing facility.

Medically necessary: Healthcare services or supplies that are needed in order to diagnose or treat an illness, injury, disease, condition, or symptoms and that meet accepted standards of medicine.

Medicare Advantage: Also known as Medicare Part C. This Medicare plan is offered by private companies that contract with Medicare to provide you with Medicare Part A and Part B benefits.

Medicare-approved cost: The amount Medicare will pay for a specific healthcare service or treatment.

Medicare Part D: A program that helps pay for prescription drugs for people with Medicare.

Medigap: Extra health insurance you can buy from a private company to pay healthcare costs not covered by original Medicare (for example, co-pays, deductibles, and healthcare if you travel outside the United States).

Minimum essential coverage: The amount of insurance coverage a person needs to meet the individual responsibility requirement under the Affordable Care Act.

Open enrollment period: The time period when a person can sign up for a health insurance plan.

Out of network: Healthcare services received by providers not contracted with your insurance plan.

Outpatient: Healthcare services you receive without being admitted to a hospital or healthcare facility.

Premium: The amount of money that you must pay for health insurance. You (or your employer) may pay your premium every month, every quarter, or once a year.

Prior authorization: Getting your health plan’s approval for a service or prescription ahead of time to be sure that service or prescription will be covered.

*The CIMplicity program is provided as a service of UCB and is intended to support the appropriate use of CIMZIA. The CIMplicity program may be amended or canceled at any time without notice. Some program and eligibility restrictions may apply.

†Eligibility: Available to individuals with commercial prescription insurance coverage for CIMZIA. Not valid for prescriptions that are reimbursed, in whole or in part, under Medicare (including Medicare Part D), Medicaid, similar federal- or state-funded programs (including any state prescription drug assistance programs and the Government Health Insurance Plan available in Puerto Rico), or where otherwise prohibited by law. Product dispensed pursuant to program rules and federal and state laws. Claims should not be submitted to any public payor (ie, Medicare, Medicaid, Medigap, TRICARE, VA, and DoD) for reimbursement. The maximum annual benefit amount is $15,000 per calendar year. The parties reserve the right to amend or end this program at any time without notice.

CIMplicity® Covered™ Eligibility: Eligible patients with a valid prescription for CIMZIA can receive treatment with the CIMZIA Prefilled Syringe at no cost for up to two years or until the patient’s coverage is approved, whichever comes first. Program is not available to patients whose medications are reimbursed in whole or in part by Medicare, Medicaid, TRICARE, or any other federal or state program or where otherwise prohibited by law. Patients may be asked to reverify insurance coverage status during the course of the program. No purchase necessary. Program is not health insurance, nor is participation a guarantee of insurance coverage. Limitations may apply. For initial enrollment into the program, the patient must be experiencing a delay in, or have been denied, coverage for CIMZIA by their commercial insurance plan. To maintain eligibility in the program, the following are required: (1) a prior authorization request has been submitted and/or coverage remains unavailable for the patient; and (2) if the prior authorization is denied by the payer, the prescriber must submit an appeal within the first sixty (60) days of the prior authorization denial and a prior authorization must be submitted every six (6) months thereafter or documentation as may otherwise be required by the payer. UCB reserves the right to rescind, revoke, or amend this Program without notice.

If you are uninsured, other financial assistance may be available. Call ucbCARES™ toll free at 1-844-599-CARE (2273) for more information. The CIMplicity program is provided as a service of UCB, Inc., and is intended to support the appropriate use of CIMZIA. Any CIMplicity program may be amended or canceled at any time without notice. Some program and eligibility restrictions apply. Please consult your doctor if you have any questions about your condition or treatment. You are encouraged to report negative side effects of prescription drugs to the FDA. Visit www.fda.gov/medwatch, or call 1-800-FDA-1088.