Insurance Questions/Open Thread

[Lucky Lou]

Happy Weekend…………This Wednesday I go to get my BX.. Shortly there after, TX. I have heard so many things about insurance that I do not know what to expect. I have Tufts insurance and am going to call them this week to begin to ask questions. Please give me some feedback as to what will these people we say, pay, and what they will reject, and perhaps how to handle them and this. What have been your experiences with your insurance providers, especially Tufts, (but not specifically)? How much do the meds cost? Was it necessary to have special approval first? Where did you get the meds, regular pharmarcy....Blah Blah Blah....... I mean right now I am a hepper of “unknown status”. .Help me out…Spit out the answers!  Open Thread as well.
Thank you,
Lou

[Docsgold]

I have BCBS and have only had a problem with them paying for 3 sets of labs.  They want to determine if this is a pre-existing condition and need more documentation from the physician ordering the labs.  I had no lapse of insurance between jobs.  They have paid 100% of everything else, from labs (and there have been many), BX, physicians visits, including those I have to see for side effects--dermatologist for rashes, and ENT for sinus problems.  I have continued to fight the insurance co and they have paid 2 or the 3 pending claims.  I have found it to be to my benefit to keep at it and they will pay.  

I did not get any special approval before tx, but I did check on the cost and availability of the medication.  At my local Wal-Mart--their cost--for EACH Rx (Peg/Copeg) is $1800--wonder what the mark up would be to me?  Anyhow I have been told the tx is approx $25,000.  To get the meds locally is $45 each/per month, so I mail order 3 mo supply from the insurance co and I get 3 month supply for 2 mo cost.  I am getting off pretty cheap compared to others.  Good luck to you.

[cuteus]

It is 11am ET PBS is broadcasting a show on hep c right now.

[cuteus]

well, that was an interesting show, nowhere did they mentioned sexual transmission of HCV, but...a firefighter got it from a prisoner spitting in his ....EYES! how weird is that after yesterday.  The difference is she spit BLOOD in his eyes, not saliva. I got to meet Dr. Dieterich in that show, since I did  not have to meet him in real life for my extension. pretty cool.

Lou; i gave my input on the bx over "there" as for the meds, some companies need to prior approve the meds, including Procrit and Neupogen, so check with yours. I  only pay $10 for 3 months supply of  Peg and 10 for riba. I am blessed with great insurance, they have not questioned any part of my Tx. My insurance does not pay in network for oral chemo for Ca, but it is ok for HCV, I guess.

[DH Bill]

This is a good question as most people don't consider this. Here is the cost of my first 24 weeks with my first insurance carrier before my company swiched:

Pegasys-$1,292.49 for 4 weeks- 4 shots $40 co-pay
Copegus-$1,039.89 for 180 tablets      $20 co-pay
Ambien-$95.99 for 30 10mg tablets     $40 co-pay
Effexor- can't find records but co-pay was $40

*Peg&Copeg require prior approval as do some other drugs

I was on the committee at work to approve a new in. carrier and I got a eye ball to eye ball hand shake guarantee that I would have no problems with new carrier U-Select/Healthnet but was lied to as coverage was denied. After MUCH fighting with them in the middle of tx this is what they paid:

Pegasys-$1,873.80 with a 20% co-pay
Copegus-$1,039.89 $40 co-pay
Ambien- got it on line as doc gave me so much grief about daily use and his fear of addiction
Effexor- weaned off and stopped at 24 weeks (withdrawl was horrible man)

Drugs for low wbc&rbc are as expensive as peg

This is something to really do your home work on if you are not financialy well off. Others have had to pay a lot more and shows one reason why agood doc is worth his/her weight in gold. Most pharmacies have all this.

dh

[GulfCoast]

Hi Lou,
I haven't had any problems with my insurance carrier (Humana), I just have to pay any co-pays, deductibles per the coverage.

I pay $20 co-pay per perscription for 1 month supply. So for pegasys/copegus it's $240 for the 6-month tx. I pick up at my neigborhood Eckerds. I could get it cheaper via mail but feel comfortable picking it up. Irritates my wife but I just don't trust delivery as we both work long hours. I would hate to have my pegasys simmering in the hot Florida sun till I got home.

I feel fortunate as out insurance carrier was changed several months before dx from Cigna to Humana. I believe another poster stated that they were having issues with Cigna not accepting treatment for HepC as treatment was still "experimental" due to the SVR rates. I can't verify this but that certainly would bite.
Hope this helps.
Peace - Gulfcoast

[Honey15637]

Wow Rev,,,You must have one heck of a plan. I also am United Healthcare and pay 15 copay for dr visits and get 3 months supply of meds for 15.00 and I thought that was good!

[hope2Bok]

Don't forget everybody. It depends on the state you live in and also the plan that your company purchased for you.
Anne

[stagelines]

this was also posted at Hep-c out of bounds but it may be of use to someone here also

hi lou
been content to lurk, but saw some questions that you had that i might be able to really give you a hand with.

first, what costs are covered will be specific to your own policy with your insurance company. i have blue cross hmo. they cover full cost with a token copay on most everything except elective procedures (biopsy, etc) and self-injectibles (pegasys, and if necessary, procrit and neupogen). i have a 30% copay for the self-injectibles.

now, if you wind up paying a substantial percentage of your costs of TX you will want to make sure you have priced your medications at MedMark, formerly Fisher's Specialized Pharmacy Services. www.medmarkinc.com
they are located in Pittsburgh, and specialize in hep-c medications. my cost for four weeks worth of pegasys & 30 days worth of copegus is under $500, and was a little higher on the first prescription. that is about a fourth of what my cost was going to be under my coverage at my local pharmacy, and cheaper than i found amywhere else.

They ship overnight at no cost, and have shipped my order to me without payment due, and allowed me to make payments on my balance. they prefer the balance to be paid off before the next shipment goes out, however.

I spent almost a month waiting to start treatment because of red tape between the insurance company and my GI specialist. I have also had some issues getting meds shipped at my refill times for the same reason, but medmark has done their part promptly and accurately.

if you are put on pegasys, request the vials rather than the prefilled syringes. also request a few additional syringes. the vials hold about 20-25% extra medication, and save this in your additional syringes for a bonus dose every month. you may want to extend treatment after your insurance stops covering costs. research indicates that you want to continue treatment 36 weeks after viral clearance. a 48 week regimen is fine if you clear at 12 weeks, but if you do not, you may be glad that you saved your leftover pegasys.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14999598

consistently taking all of your meds on time has a significant effect on your likelihood of SVR.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12360468&dopt=Abstract

staying on full dosage of ribavirin if at all possible during your course of therapy has a substantial effect on SVR as well. (66% vs. 46%)

http://www.hivandhepatitis.com/2003icr/03_assld/docs/pegasys/102703_g.html

and lastly if you have not looked into zadaxin you may want to if you can swing it. it is approved in something like 25-30 countries for hep-c but not yet in the us. it appears to greatly improve response rates as well as reduce SX of standard combo therapy.

http://www.hivandhepatitis.com/2003icr/03_assld/docs/1109/110903_c.html

http://www.communityonthe.net/board/showthread.php?s=&threadid=910

miles goes into discussion of zadaxin in depth on his irreverant site

http://www.mkandrew.com/

but he has rearranged his pages and i do not have a direct link to the zadaxin info. zadaxin works involving a t-cell shift to be especially effective killing off the last of the virus that slips under the radar. these minute amounts of the virus under detectable levels are responsible for relapses.

hope this helps. i really appreciate your work and sacrifice that you have given to this community

[Lucky Lou]

I just wanted to thanks to everyone in case this thread stops. Great info.
Rev, your bankrupting those insurance companies! At a boy!!

Stageline: I think you violated my copyrights! My law firm of Dowey, Screwem, & Howe will be contacting you shortly.  (great info, thsanks again.)

I actually feel better after reading these post.It seems to me that most with insurance get the majority of the stuff paid less the co-pays off course. Then we have to fight sometimes, Ok, know that game. if they want to bust chops they will end up at the depot at this stop. So I feel better. My bx is costing $350 at the time, my SO says it's the total deductable.

She also read the thread with Deep z and said' "Oh yah, he's definitely a real person" I asked laughing "how do you know?" She answered "I dated him" and walked away...I stopped laughing

Make it a great Sunday! Thank you!

[Showboat]

Hey....you are quite a Character.....you are so funny....you keep me laughing so much.  I find that very healing for my soul.  Good luck with your bx on Wed (I am sure we will be "talking" before then)  :>)  Good luck with your insurance issues.  I have the same deal as our reverent Reverend....(it is almost too good to be true!!!!!!)