CGHS, ECHS, ESI and State Schemes — for Cancer Drugs and Treatment

It depends on whether that specific drug appears on the current CGHS approved drug list. Drugs on the list are billed directly to CGHS at the approved rate, and you pay nothing beyond your co-pay category. If the drug is not listed, your oncologist can apply for special approval — this is a formal process and CION counsellors are familiar with it. The answer to whether your specific drug is covered takes one check of the current CGHS formulary, which the scheme desk can do on the day you enquire.

PM-JAY can be used at any hospital empanelled under the scheme. CION centres participate in the PM-JAY network, and the counsellor can confirm which centres accept PM-JAY and for which procedures. Bring your PM-JAY card or the mobile number linked to your Ayushman Bharat account when you come in — the team can verify your eligibility and listed procedures on the spot before treatment is planned.

For schemes with annual coverage limits such as PM-JAY, costs above the cap are not automatically covered. Your counsellor will review whether any additional state schemes apply, whether a drug manufacturer's patient assistance programme covers the gap, or whether a phased treatment plan could remain within the annual limit. For CGHS and ECHS, the cap is per procedure rather than per year, so the question arises differently at each stage of treatment, and the counsellor will map this against your treatment plan in advance.

A surviving spouse of a CGHS card-holder is entitled to continued coverage as a dependant. The card is updated at the CGHS office on submission of the death certificate and marriage certificate. Adult children who were previously listed as dependants would need to check whether they still meet the dependency criteria under CGHS rules. The counsellor can review your family's specific situation and advise what documentation is needed to continue without a gap in cover.

If your employer is deducting ESI contributions, you are registered — ESI registration is the employer's obligation, not the employee's. Your insured person number appears on your salary slip or on the ESI card if one was issued to you. You or your HR team can confirm your registration on the ESIC portal using your Aadhaar or employee details. To use ESI for cancer treatment, you begin with a referral from your nearest ESI dispensary or hospital to an empanelled facility — the counsellor can explain how this works for your situation.

Pre-authorisation adds a step, but most schemes have provisions for emergency approval when treatment cannot safely wait. Your oncologist makes a written case for clinical urgency, and provisional approval is typically issued quickly in genuine emergencies. The counsellor's job is to have all documents ready before the approval is needed, so that when approval comes it is the only remaining step. Starting the process on your first visit — rather than after staging is complete — is what keeps any delay minimal.