Blue Shild PPO Denied peg-intron?

[booocooo]

Did any of you have problems getting a PPO to approve meds?  I got two letters today, one saying that I am denied Peg-Intron beacuse I did not try pegasys.  And the second said I was denied Ribaviron because that is only approved for people with  hep C using peg-intron or pegasys with geno 2 or 3.   HELLO INSURANCE CO....I'm HCV and geno 3!!!!  SOOOO FRUSTRATING!  Sorry, needed to vent.  Any advice would be great!  Thanks!

BC

[fretboard]

That sux big time, I'm not on treatment yet, but I have Blue Shield as my HMO and I've always wondered what they would cover, should I need their assistance.  I'm not even the same geno type as you are, but I can understand why you needed to vent.  Society has to accept this virus and quit treating us heppers like they did the leppers.  It seems to me that we have been dealt a double whammy.  We are sick with a virus and if that wasn't bad enough, we have a virus that has an unshakable stigma attached to it.  Once society accepts this virus as just something that millions of Americans caught, we will continue to get the short end of the stick.  Your post is just a symptom of the bureaucratic BS that can be easily passed off as making sense by the insurance companies.  Once again they squeeze their way out of paying by saying "oh you didn't take the medication we picked for you", that's like communism.  God Bless

[pigeonca]

Blue Shield hasn't changed a bit.  30 years ago I had Blue Cross/Blue Shield insurance in Illinois.  They played this game of denying benefits, and once you put up a figght, they would cave in and give you what you needed.  They also made it quite difficult to fight them, but if you went through the paces, you almost always won.  I'm sure that many people just gave up.  Imagine how much money that saved Blue Shield.

[koala68]

I agree with Pigeonca. Don't give up! Same thing happened to me 6 months into treatment last year. Got a letter from Blue Shield stating that they had to interrupt Tx because Interferon/Riba has only be FDA approved for 6 months max. (which is not true, it really depends on your genotype). I informed my Hepatologist which sent them the justification they needed.
To me Blue Shield is managed in a very capitalist and efficient way. It has nothing to do with communism. Why insure sick people? It just cost money. So yes, they artificially introduce some bureaucratic elements to discourage more people but that's just an illusion of inefficiency. I bet they send the same letter to everyone. Even if a few percents of the people give up, it translate into millions of $ saved every year.
Good luck!

[Bobby1952]

   Who ever sent you those letters doesn't know what they are talking about. Get your Dr involved. He should be able to explain it to them. If not him then one of his PA's or nurses.

Good luck

Bobby

[Bill1954]

You just might have unknowingly been dealt a slick hand here. HCV drug manufacturers have Patient Assistance Programs (PAP’s) in place to deal with scenarios like this. I don’t know if you have been prescribed PEG-Intron or Pegasys, but often a letter of denial by insurance opens the door for no/low cost assistance.

Call either (which ever is appropriate):

Pegassist (Roche Pegasys system): 1-877-734-2797

Commitment to Care (Schering- Plough PEG-Intron system): 1-800-521-7157

and ask to speak to a counselor regarding your situation. You may qualify for no cost HCV meds shipped to your home or office hassle free. I’ve received almost two years of free meds, no co-pays required from Commitment to Care. The people there rock, and the approval process moves quickly; it can take as little as a few days.

Good luck to you—

Bill

[Mr Liver]

What's wrong with Pegasys ?

[GrandmaBRZ]

4 years ago I had a reimbursement problem with Blue Cross (CA).  It went on for a couple of months.  I let them know I was going to get in touch with CA Dept of Insurance.
Check was in mail next day.  Maybe that could help your situation.

Good luck.

[Mary4now]

****, these insurance co. have no problem taking the $ for premiums, then I cant believe what their allowable amounts are..
I had to call/write the Public Regulations Commission re: my insurance lapsing, now the commission has asked me to send all my bills so they can monitor and make sure the insurance company is paying for everything they should.
I call the insurance co. whenever I dont understand what the heck they are talking about, one time they didn't cover a visit and I called and they said they would bring it up at some meeting to re'evaluate.  I think I'll make my copies and let the PRC monitor them....  
I dont know if the PRC in your area would be of any help.  They investigate insurance companies... I even had some one from BCBS call me and say they received the PRC complaint and they are reinstating my insurance w/o any lapse time..  no wonder the health care system is so screwed up with all this paper work and business people making medical decisions.    Gawd help us.

[hoocbud2]

I was also denied to start with.  I contacted Commitment to Care went to their web site first downloaded their application and then called and talked them.  Downloading the application saves time rather than waiting for one to arrive in the mail. I know that they will want 4 weeks of pay stubs for yourself and spouse (if it apply's) and a cost of medical expenses you are paying now  I faxed my application and insurance info to them. With in 2 days I received approval from my insurance,  Was also sent a letter that if something changes with my insurance to get back with them. (Schering- Plough PEG-Intron system): 1-800-521-7157. It all happened in less than 4 days.  They do seem to really want to help.

[kickboxingmom]

I also got that denial letter with all Drs.approval behind me.I wrote to the insurance CO myself and stated the problems.Sent copies of proof.It wasn't long till I was approved.Here's one of the articles I sent.Good Luck !   T.


Evolving Therapeutic Arsenal for Hepc. In a nut shell
New Directions in Hepatitis C Therapy: A Look at the Evolving Therapeutic Arsenal
Posted 09/05/2008
Zobair M. Younossi, MD, MPH, FACP, FACG
Author Information
Introduction
Chronic hepatitis C continues to be the most important cause of chronic liver disease in the United States, potentially resulting in cirrhosis, hepatocellular carcinoma, and the need for liver transplantation. The only US Food and Drug Administration-approved treatment for hepatitis C is combination therapy with pegylated interferon alfa and ribavirin (standard of care), which leads to a sustained virologic response (SVR) in approximately 80% of patients infected with hepatitis C virus (HCV) genotype 2, approximately 60% to 65% infected with genotype 3, and approximately 40% of patients infected with HCV genotype 1.[1-3] If SVR is achieved, durable response is quite likely, providing patients with an excellent chance for long-term viral eradication.
In addition to a relatively low SVR rate in HCV genotype 1 patients, other challenges associated with the current anti-HCV treatment regimen are its side effects and the required duration of therapy, both of which interfere with patients' adherence to the full course of antiviral therapy. In fact, recent reports suggest that the inability to maintain the optimal dose of both pegylated interferon alfa and ribavirin, especially early in the course of treatment, is associated with a lower rate of response to the current standard of care therapy.[3] This may explain, in part, the difference between response rates reported in randomized clinical trials (indicating the efficacy of treatment) compared with the response rates reported in clinical practices (indicating the effectiveness of treatment). To overcome these challenges, recent investigations have focused on optimal management of treatment-associated side effects such as anemia and depression.[1-3]
In addition to managing side effects, research has also focused on developing models to predict low response probability in an effort to avoid futile treatment, and high response probability in an effort to support a full regimen for patients likely to achieve viral eradication. These predictive models are based on viral kinetic data at weeks 4, 12, and 24. Patients who achieve rapid virologic response (RVR; undetectable HCV RNA [< 10 IU/mL] by polymerase chain reaction [PCR] after 4 weeks of treatment) have an excellent chance of achieving SVR.[1,2] In contrast, failure to achieve an early virologic response by week 12 of treatment (a minimum of 2-log drop in HCV RNA from the baseline value) is a reliable negative predictor of response to this combination therapy regimen.[1,2] Furthermore, patients who continue to have detectable virus after 24 weeks of therapy are unlikely to achieve SVR and are considered "nonresponders" to combination therapy.
Although findings on viral kinetics and adherence can help clinicians individualize therapy and maximize SVR, many patients, especially those infected with HCV genotype 1, fail to respond to the current standard-of-care treatment. This has led to the development of new strategies and medications for HCV treatment. Although a number of approaches are under consideration, 3 strategies appear most promising: (1) improving the pharmacokinetics and side-effect profile of interferon; (2) improving the pharmacokinetics and side-effect profile of ribavirin; and (3) targeting viral enzymes required for HCV viral replication. This report discusses the most recent findings with regard to these new approaches to the treatment of HCV infection, with special focus on specifically targeted antiviral therapy for hepatitis C (STAT-C) regimens.[4,5]

[cb867]

I have Blue Cross/ blue Shield. I am on pegasys and ribovarin. I am type 2. It only costs me 80.00 out of pocket. The doc said thats because of your genotype and iral load. They had to know my VL to authorize it. They should cover everyone that has the same ins.

[FloridaMouse]

Yes, Blue Cross is a real flipping picnic.  Our group health insurance company switched over to Blue Cross the first of the year and this is what we have been through in just 8 months.

1.  At the time of the switch I was 58 weeks into a 72 week course of treatment.  Blue Cross decided to cut my treatment off claiming there was no proof of efficacy beyond 48 week.  My local GI and my GI at Shands had to get involved in the appeal.  It took over a month, thank goodness Roche stepped in and helped me out for a month.  Oh get this, they would approve the Riba but not the Peg.

2.  They tried to cut off my Aranesp/Procrit saying my PCP said it wasn't medically necessary.  At the time this happened my PCP wasn't even in the country.  The truth was they cut my off because my labs showed a normal hgb.  Uhhh... Duhhh... it was normal because I had been taking Aranesp.

3.  My husband had surgery for sleep apnea in May.  Not only did the doctor call ahead of time to confirm benefits, so did my husband.  My husband even confirmed what each co pay for each provider would be (i.e., surgical center, anesthesiologist, pathology, doctor, lab).  Blue Cross paid the surgical center, the anesthesiologis, the patholoy and the lab.  When itcame time to pay the doctor, they dediced to put the claim under review to see if the procedure was medically necessary.  This is August, the doctor has still not been paid.

4. Shands has not recommended that I do something called suppresive therapy.  It's similar to the maintenance that failed (Halt-C) except it included Riba.  As expected it has been denied by Blue Cross.  Dr. Nelson at Shands already talked to Blue Cross' medical director who doesn't have a clue.  The claim has now been sent out for independent medical review.

Needless to say I am not a fan of Blue Cross at all. (Note this is Blue Cross of Florida, Health Options PPO).  I  have an endoscopy and colonoscopy coming up on Tuesday.  I fully expect Blue Cross to give me a hard time over these procedures.

Expect to fight every single claim that is submitted to them, expect to play the telephone shuffle came and make sure you get EVERYTHING well documented and whenever possible ask them "can you send me that in an email please".

Mouse
P.S.  Do ya think this thread hit a nerve with me LOL

[alagirl]

I have BCBS and they paid everything but a small copay on my meds (pegasys though, not pegintron).  Also, they paid for numerous hospitalizations, blood transfusion, port procedures, etc, related to my treatment.  I think it really depends on which group you have.  

[sail10]

I have blue cross blue shield and i am Geno type 2 , on pegasys and ribivarin total cost per month is $30. for pegasys and $10. per month for ribivarin . call Sandy Sawyer my case manager , R.N . AT BLUE CROSS blue shield -1-800-462-3275 or better e- mail her at -   sandra_sawyer***@****  . sail