INSURANCE

Most know my HGB went down to 9.3 about 3 weeks ago. Even after 3 procrit shots. Last week it was up to 9.5 and i can  tell it seems to be up more. Anyway my hepo was just giving me the shots till last week until his regular office girl got back to send them the proper paper work. Well they gave me the RX last week and i went to the drug store to get it. The drug store told me they needed to call my insurance to get the cost to me.

Well they told the drug store they wouldn't cover it and called my doctors office and told them that their doctor a GP that works for the insurance company said after doing some research that if my doses was lowered then i Wouldn't need it. Well last week i got an email from my hepatologist who called them is self. If you think a patient can **** a doctor off a gp at an insurance company telling a hepo how to do his job really brings the best out of him. I ask my hepo if they taught him some of those words at med school? He emailed me back laughing and said no that most from his patients. Anyway the insurance company decided to see it is way.

[jmjm530]

First of all congratulatios on rising hgb and getting your Procrit approved!

Cursing aside, it's very important for anyone having insurance issues like this to understand the treating doctor can weigh HEAVILY into the decision on whether or not a particular drug (or procedure)will finally get approved. Often it's simply the difference between a doctor (or his office) getting actively involved or not.

In general, insurance companies will turn down many initial requests as a matter of policy/guidelines. This policy often turns out to be very flexible as Camdo found out, as I've found out, and as many have found out who had their doctor strongly advocate for them. Another reason why it's so important to have the right medical team behind you, and to discuss rescue drug intervention with them BEFORE you start treating.

I don't know how many times I've heard here you can't get Procrit until your hemoglobin drops below 10, etc. I know for a fact that many of us received Procrit at higher levels (I got mine at 11.4) but only because our medical team agressively intervened on our behalf. Same with more frequent PCR testing. My first NP told me she would have to "fight" for a 4-week PCR. My second doctor got me PCR's weekly at one point because their office made the effort and backed up their request with knowelegeable and persuasive arguments.

Some doctors -- like mine and apparently Cando's -- intervene as a matter of routine policy. Others are reluctant either because they lack the specific experience getting around insurance companies guidelines regarding HCV, lack the specific HCV protocol knowledge, or simply because they don't want to spend the time dealing with the insurance companies.

I hope no one takes this as a criticism of their medical team but rather as another reason to become your own medical advocate and to make sure your medical team is as well in all respects -- including getting insurance approval for rescue or other drugs.

-- Jim

[jmjm530]

Here's another anecdote on how different doctor offices get different results from the same insurance company.

During treament, I wanted to try Rhinocort for sinus problems. My rx was turned down because Rhinocort was non-forumulary or something like that.  My PCP's insurance person called the insurance company and was also turned down.

A few weeks later I saw an ENT. I explained I was turned down for Rhinocort. He said his "girl" would handle it. I told him what happened last time with the insurance company. He said that his office knew how to handle it because they go through this five times a day. I got the Rhinocort.

Right doctor with both the right treatment experience and the right attitude -- the latter probably being the most important.

-- Jim

[way]

What you said is so true.

And also maybe to some extent the Doctors may say that the ins co won't cover something when really maybe THEY don't think it's necessary or don't feel like messing with it.

That happened to me with my 4 week PCR too. I'M SURE the Doctor said it WASN"T COVERED. I even posted about it. Then on my next appt. I told the Dr. that I REALLY wanted it, and was prepared to say I would even pay for it myself when the DOC. said, "OK no problem." Surprised, I said "I thought you said the ins. wouldn't pay?" And he said, "They will if I order it".

This made me feel very sucessfully pro-active-but also left me wondering what was up with that.

[jmjm530]

OK. Last story, I promise. (Can you tell this is a pet peeve of mine :) )

Went to a derm not too long ago. Was prescibed a particular topical steroid. Insurance company turned it down.

Called back derm's office and left message for derm or his nurse to help out.  Neither called back.

Called back in two days and was transferred to someone unrelated to my treatment. Let's call him "Unrelated".

Unrelated said doctor and nurse are busy but he will speak to them and get back to me. He didn't.

I called back Mr. Unrelated the next day and he said he couldn't speak to doctor or nurse but he did speak to another doctor in the office (who I had never seen) and the other doctor suggested I take another steroid instead.

I thanked him very much and switched derms the next day.

-- Jim

[Myown]

Wow!! thanks alot...you guys just gave a newbie something to bite into and to bring up when at the doctor this week. I thought i had my list of questions complete at this point. This is something I have to discuss before anything gets going with tx. Thanks!!

[amirtracy]

Just wanted to say Way to Go! Glad your hmg is rising and glad you got the insurance worked out. couldn't happen to a nicer guy...t.

[NYgirl]

First off - STOP COPYING ME~! I INSIST it right now!  9.3? What are the odds we'd both fall to that number at the same time?

I'm back on every 3 days Epogen myself and WAItING for it to kick in.

I'm sorry my friend - it makes me laugh that we have the same number (even though you went up a bit).  Remember it can take up to 6 weeks to kick in (unfortunately) and then chances are one day you are going to get the CBC done and you will be over 15.

That's what happened to me last time.

PS They didn't want to approve me either (hey at 6 thousand dollars a box why WOULD THEY?) for 2/3 times a week but my pharmacist got it to go through for me. That seems like ten years ago now but it was only ten months...wow.

[FlGuy]

First, CDM and NYG need to stop playing hgb Limbo.  There's no prize for being Beagle-like.
Something that was mentioned here a couple of times is the (possibility) that doc's who actually administer rescue drugs, like Neup and Procrit may have fewer obstacles to overcome when it comes to insurance, as compared to writing Rx's for them.  I was a regular at a hemotologist and frequently received Neup (not procrit) and there was never an issue with insurance, rx approvals, pharmacy co-pays etc.  It leads me to belive that drugs administered during the course of care are approached differently than rx's.  Might be worth a look

[friole]

Say what?  A general practitioner that works for the insurance compnay did some research and decided you didn't need it?  Give me a break!  Too bad we can't inject some of these folks with instant anemia.  Your hepatologist is my hero.

I usually have to go the other way around.  My doctor denies something, using the insurance company as an excuse, and then I email my case manager at the insurance company and take his reply into the doctor who then honors my request.  Fortunately, I had no problems getting the Procrit at about 10.6 hgb.  I know insurance companies have all levels of plans.  We pay a pretty high premium for ours but it sure has been worth it during the course of this treatment.

can do - sure glad that hgb is on the rise
bean

[cajunlady]

Things will work and all will be fine.  Can't be any other way; for you are CAN DO MAN.  Best of luck keeping everything going in the right direction.

Cajun

[Mister beagle bailey]

Glad to hear yiur HGB is on the rise and that you won the battle againist the ins giant.  It was good that your doc kept fighting.  Beagle

[FlGuy]

Now that you are somewhat recovered Beagle, what's next?  House-hunting, vacation, life-loving?  I think I read that you were drawn for pcr recently?, If so, when are results expected?  Haven't been to Hutch lately, but heading there this weekend to kick-back a bit.  Take care Beagle.

[merlino]

Hi, got back results from ultrasound-all normal. Still a few more things to cover b4 tx (like Dentist). I read tx hard on teeth. How r u?

[FlGuy]

All's well here and speeding toward September. Good to see your continued determination. I see no second guessing in your posts. I've read that one of dental-related issues is around bone loss, brought on by the hcv effects on vit. D.  It's a good idea to check in with the DDS if nothing else to get a current dental state, get a tune-up and establish a baseline condition for yourself.  Picking yourself up for a dentist visit is not the funnest thing to do on tx.  Hope dentist/doc can give some suggestions for vitamins/supplements that can augment tx without being stone-causing.

[Mister beagle bailey]

Yes, house hunting I will go. Will do my PCR in about 2 months but I did do one at week 23 on tx and it was undetectable.
Hope you have a relaxing time on Hutch this week end.  When do you go to Miami?  

Beagle

[FlGuy]

Actually, I was at Miami Beach early this AM. But, the appointment is Aug 11.  Got to Miami Beach too early to see the REAL sights  ;)

[Mister beagle bailey]

If you want to see the real sights in Miami you have to wait till night fall.;)  You see your dr on the 11th and NYgirl see's dr J on the 5th.  
Do you live full time in Broward or Miami-Dade counry and have Hutch as a treat?

Beagle

[FlGuy]

Live in Boca, work in Ft. Lauderdale, play in Hutch, eye strain in South Beach.

[Mister beagle bailey]

If you want to see the real sights you have to wait till after sun down. ;)  Nygirl also has an appointment to see dr J on Aug. 5th for new treatment if need be.  Do you live full time in Broward county and Hutch is your home away from home?

Beagle

[Mister beagle bailey]

Sorry I reposted the thing as on my end it didn't show as being posted.  Boca is a great place, we concidered moving there years back.  We loved the park on A1A off of Spanish River Drive.  Before we moved to Florida we use to stay in Boca on our trips.

Beagle