insurance woes

is it legal for my insurance to pay for avastin the drug, but not pay for my doctor's fee for the injection?? i have diabetic retanopathy.

[John C Hagan III, MD, FACS, FAAO]

Its not whether it legal or illegal its what does the contract between you and your company say. You may need to file an appeal and/or ask the surgeon's staff to help you file.

JCH MD

[magic23]

my surgeon has written a letter to blue cross/blue shield and still they wont pay on my surgery or on my avastin injection, only laser treatment which is more expensive and less effective than the injections. my company is self insured and they say money is not a factor.

[John C Hagan III, MD, FACS, FAAO]

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[John C Hagan III, MD, FACS, FAAO]

You may be getting a taste of socialized state medicine. The NICE board in England has decreed that avastin and lucentis are too expensive for socialized medicine. They use it in 1 of 5 cases of need and then only in one eye.

Right now in the USA we still have some freedom of choice and options. Let's hope we can keep them.

You can:

1. As I said file an appeal to the company
2. Report the matter to the state insurance department.
3. Pay for it on your own. It can keep sight from worsening 75% of the time when it is started. It is worth your own money to keep your sight.

JCH MD

[John C Hagan III, MD, FACS, FAAO]

Last comment

You can ask your Eye MD to use AVASTIN it is MUCH MUCH less expensive than Lucentis and for almost all cases just as good. It is VERY affordable

JCH MD

[londonpride]

You may want to make a political point again, but your comment about the NICE board in England is just not true.  NICE guideline TA155:
"The NHS should cover the drug cost of ranibizumab for the first 14 injections in each eye being treated. If people need more than 14 injections per eye, the manufacturer of ranibizumab has agreed to take over the drug cost from the NHS."

(Ranibizumab is Lucentis)

If you insist on making political points about the NHS, please get them right and preferably quote your sources.

[OldNavy966]

I too had negative opinions about socialized medicine.  After seeing so many opthamologist, I now believe somebody needs to police these guys.  They won't stop until somebody stops them.  Wish I was still in the Navy and seen a government opthamologist who wouldn't upsell.