Insurance denial of procrit

[jrgordon]

My wife has been undergoing combination drug treatment for HepC.  It has been hell on her.  About half way through, she became anemic (around 9.3 or lower), and her doctor presribed Procrit.  She has been getting those shots for about 15 weeks.  They help.

Last week the HMO (a Coventry Health Care company) informed us that the procrit was not covered.  They called it "experimental".  The shots are $1300 a pop, a lot more money than we have.  From what I can tell, while not FDA approved for HepC therapy, Procrit is not experimental.  I believe in my doctor - she is caring, thorough, and insists this is the best treatment.  

The psychological effort to deal with this therapy is significant, without the HMO laying this on us.    

Is there any advice out there for dealing with this situation?  Similar experiences?  Has anyone fought this battle?  Do other Insurance companies have this policy on the treatment?  It seems a lot of you have experience with the treatment - have you all been paying for Procrit shots out of pocket?  Would appreciate any guidance.

[amirtracy]

Hi. Sorry for your dilemma. It's hard enough w/out having to worry about $ and paying for meds. I'm uninsured so i know. Here's the link for free procrit. it's the pharmaceutical co's free med program and they are very liberal w/ incomes. (ex: almost $70k in the state of fla.) If you make too much there are some states that have COBRA and other programs to assist. I'm sure there will be others to come along and offer more advice. Best of luck to you and your wife.   Tracy

[amirtracy]

Ugh. HERE'S the link. (I don't know if your wife has experienced any "brain fog" but forget about it- I'm gone. (also 1/2 way thru tx)...;)

http://www.procritline.com/patientassist/intro.jsp

[jmjm530]

First see if your doctor will go to bat for you. Sometimes if they insist it's a medical necessity, the insurance companies will relax their guidelines. Make sure your doctor is speaking to a supervisor or above and not whoever answers the phone. You might also want to google "Procrit and HCV" and print out pertinent studies to both give to your doctor and/or insurance company. Lastly, you might want to contact the company itself and see if they have any financial assistance programs.
http://www.procrit.com/

Good luck!

-- Jim

[friole]

Here is another idea.  Sometimes it is the code the doctor uses.  Instead of using something referencing Hepatitis C or Hemolytic Anemia, he should try using a code that is specifically used for chemotherapy treatment - which is what this is.  Often times it will be accepted then. I am sorry i cannot be more specific, that is all i know
frijole

[beamishboy]

at doc's office today the nurse told me about an old man suffering anemia caused by cancer/chemo & couldn't afford the procrit..I offered my procritline card which she copied,then called them.Said-'he has insurance..so not eligible" ..any recourse options?   and he can't afford the expense outof pocket ....poverty and health problems seem like common bedfellows and often those with the greatest need don't know how to 'work' the system..

[can-do-man]

Theres an elderly lady in her 70's with cancer. She was going to the doctor for the shot. Medicare part B will pay 80% of what they allow. Her cost was still 78.00 per shot though. When she told me this and said it was still costing her to much and she had that new drug program medicare part D but didn't help her. I had procrit fax me the forms and took them to her doctor. He had never even heard of it. He filled them out and she got it. She told me even though she had insurance they covered it because the procrit was more then 5% of her income. So i wouldn't take what that nurse said to heart. People can still get it free even with insurance if their income is low.

Best of luck to him

[can-do-man]

Also this one. Thanks to Friole......

Amgen
Safety Net Program
Products covered:

Epogen (erythropoietin, EPO)
G-CSF, Neupogen (filgrastim) Contact  1-800-272-9376  





Program Eligibility  
--------------------------------------------------------------------------------
The patient must meet one of the two following criteria to qualify:
Annual income is below $60,000 for an individual and has no health insurance or Medicaid
Or
If insured, the patient must demonstrate difficulty with making co-payments for the drug by showing that at least 5% of their annual income is spent on the drug.

Enrollment Process  
--------------------------------------------------------------------------------
The doctor or the pharmacist must sign on with Amgen as a "sponsor"

Application is done over the phone. The applicant, the doctor, or the pharmacist can do this. Have income and insurance information available when you call. The process can take as little as 5 Minutes.  


Re-Application  
--------------------------------------------------------------------------------
Once a patient is enrolled in the Safety Net Program they will not have to re-apply for 12 months.  


Comments  
--------------------------------------------------------------------------------
If applying by mail the paper work can be processed within 30 days. After qualification the drug will arrive within 2 weeks. Amgen will replace used portions of the drug retroactively up to 6 months.  

[prettydamscared]

Oh sh#t, we have Coventry too and are right smack in the middle of trying to get Procrit "pre-authorized" too. Dam, that is bad news.  Sounds like you got a lot of good ideas of what to try next.  I'm a little anxious about this because our NP doesn't really use Procrit much either.  She believes in transfusing as opposed to using a rescue drug.  I never have quite gotten that idea...just doesn't make sense to me.  Well, I'm actually going to print out this thread and have a lot of back up info with me when we meet with her next week.  

Good luck with your wife's Procrit.  Let us know how she makes out with it.

[can-do-man]

My insurance also refused to pay it. All it took was a phone call from my Doctor. They quickly seen it is way. And decided they would cover it.

Beat of luck to ya

[beamishboy]

thanks for the info -i will pass it on pronto..chev,i get 1 shot aweek & hgb is still dropping again,albeit v slowly...and i haven't met this guy personally..Not sure what his reaction would be if i showed up at his home;big disoriented galoot, sweating,panting,demented grin on my face with a needle in hand-"I'll save ya!!!"

[cuteus]

as long as you have Sancho Panza as your sidekick, it should be fine>

[jrgordon]

Thanks to all for the responses.  I know our doctor will fight with us for the Procrit authorization.  I have been doing the research, and it seems that many doctors consider Procrit, rather than dose reduction, the "standard of care".  That is the case to be made.  

Also from my research - Coventry had a second quarter profit of $135.5 million this year.  Is this any way to run a healthcare system?  Deny people treatment while racking up huge profits?  It's nuts.  It is also morally repugnant.

Thanks again.  Best of luck to all of you.