PEGINTRON DENIED, please help

I am not sure what to do or where to turn.  I just received word that my insurance has decided that Pegintron is not medically necessary for me.  After approving the Incivek and the Riba on August 2nd they denied coverage of the Pegintron.  I am trying to be calm but am actually close to hysterics.  I have waited  years for this and just don't understand how they can do this.  They say the drug is covered but that I don't need it.  They keep referring me to a bulletin which states what the Interferons are covered for.  This ins co has been my ins for years they know my history.
I have explained that I am a Geno 1A 2/4.  The nurse says this is happening because they say they did not get a copy of my biopsy however the insurance is saying I don't need the medicine. They are saying that my doctor is going to have to appeal.   There must be someplace I can turn to for help.  Has anyone else had this problem?  Would you please share with me what you did?  I would be so grateful, right now I am just sick about this.
I would appreciate any advice,  I am so upset.  Words can't convey where my mind is at, I thought I felt alone when I was diagnosed, now I am really up a creek without a paddle
Thank you
Dee

[SusieS2010]

Take a deep breath. I think this will turn out ok. Your doctor can appeal. It makes no sense that they will approve incivek and ribavirin but not the drug that goes with it. Actually if you are using incivek you would probably want to use Pegasys. If you lose the appeal, Genentech patient assistance should help you by providing the interferon. I am not at my desk but perhaps someone else can provide their phone number or you can look on line.

[lynda607]

It's a matter of verbiage and I have seen this happen before but in the end the interferon is approved.  Your doctor should be able to straighten things out.  Just goes to show the insurance company knows not what they speak of when they say interferon is not medically necessary.  Obviously they don't realize they've spent thousands on the protease inhibitor and ribavirin and without the interferon you will fail treatment.  If your doctor contacts them and provides the necessary information I'm sure you will receive the interferon, just may take a little more time so stay calm and let your doctor handle the red tape with the insurance company.

What about Pegasys, will they approve it?

[EyesofBlue55]

Your Dr CAN appeal it because it IS medically necessary to go with the other drugs.It happened to me before on a sleep aid.You d r will know the process. Calm down and take some deep breaths.It will be ok.

The pegasys number is 1-877-734-2797 if you do need it but dont think you will-cindy

[Willy50]

I've heard of a few people who were turned down and whose doctor had to TELL the insurance company to prescribe.  It may be filling out the right forms or insisting but I believe you'll be approved.  

It'll happen....

Willy

[curiouslady1]

If there is malicious intent, they won't get away with it.  Grrrrrr.

[ann61]

Don't give up.  It is medically necessary and you will get the peg.  Your doctor will need to go to bat for you.  Good luck!

[wtbleep]

Can't believe that the insurers make people jump through all these hoops at such a stressful time in our lives.  Sounds like red tape that can be resolved so hang in there Dee.  Let's hope your doctor can fix this so you can carry on with tx.  Good luck!

[HectorSF]

"Pegintron is not medically necessary for me"? Really how are you suppose to treat with peg-interferon. Obviously this is not right. What your insurance company is only paying for 2 out of 3 treatment meds? Makes no sense.

Dee, of course you are angry. &*$^&# This is nonsense. But please try to calm down. This game is not unusual for insurance companies. I have Anthem Blue Cross and they did the same with me at first. This is a health insurance company doing what health insurance companies do. They love taking your money but when they have to pay they do everything they can to slow or block the process.

In my doctor's office there is one woman who only doesn't insurance billing. She knows the ins and outs of what each insurance company needs to approve coverage. Sometimes it is a form or even a certain format. (wonder why there is so much waste in the health system due to administrative overhead costs?) She has saved me from this nonsense more then a few times.

You might want to find out who handles the insurance processing at your doctor's office and tell them calmly what is happening. They have seen this many times before and should know just exactly what the insurance company needs to approve the med. It is the doctor's office that is responsible for making sure the insurance company has all the data they need. Biopsy report. Whatever. Of course let your doctor know. It is frustrating I'm sorry. But don't give up. The insurance company is hoping you will go away. Don't. Try to have faith this will happen and you will get all your meds.

Good luck.
Hector  

[Trish77]

I think you will get your meds also and I'm sorry you have to go through this stress.  This is beyond stupid, it's downright incompetent on the part of the insurance company and whoever is responsible for reviewing these things.  I'll leave it in the capable hands of the other folks to give you advice on dealing with American insurance companies.  Hang in there, Dee.  

Trish

[crossroadsec]

It's a good thing when ur Dr office helps hash out all the mess w/ the insurance co. Tell them straight up, "This overwhelms me. I need you to help." It is a maze trying to figure it all out. These people do it every day... Don't you hate it when this stuff comes up after hours too? Shakin my head.
Try and rest tonight. Karen :)

[susan400]

I am so sorry that you're having to go through this fight.  I have to tell you that whenever I have treated and had to do it with private insurance, I always had to go through this business. Every single time, I had to go through all this 'pre-authorization' nonsense.  And then, alot of times, they'd only authorize it for 90 days and then, I'd have to go back and fight through the same thing all over again.  I thought maybe that if it's easier, could you try getting through a patient assistance program?  Sometimes the drug companies have people on board that will assist the patients financially to help them with co-pays, outright insurance denials, etc.  I know this is hard, this kind of stuff makes me want to scream, but then, I have to take some deep breaths and try to work through the crazy system.

Susan400

[evangelin]

Joe was denied coverage for all three the first time it was submitted.  The Dr.'s office just had to do a little more paper work and it was done.  I bet yours will work it out too.
Hang in there.  You don't want to let yourself get all stressed before you start...not good for the immune system.  :>)
Ev  

[meakea]

Dee, if this wasn't so maddening and frustrating it could actually be hysterically funny.  I mean, really...telling you that riba and Incivik are okay but not the interferon is hysterical (in a sick way).  Some bozo at the ins company screwed up.  Call your doc and get your doc on this.  As mentioned above, it's a technical issue that your doctor CAN and SHOULD fix.

Unfortunately, it sometimes becomes like a full time job to get things to all come together for treatment.

When you do finally get approved (and you will be approved for interferon), be sure to start treatment a few weeks after your first shipment of meds arrived and then order your next shipment of meds as if you started at the time the first shipment arrived.  That way you will always have a 2 weeks bank of meds in case there, for whatever reason, is an interruption in your med delivery (and believe me it has happened to many).  Make sure, however, that your doctor knows exactly when you start treatment.  If this sounds confusing...let me know.

Keep us posted on this interferon issue.

[eureka254]

Keep in mind: that's why docs have the MDs and insurance execs usually don't get any further than a BS ;).

As others have said, take a deep breath, exhale, and just keep pushing ahead.  It's not unusual for insurance companies to be a bit behind the medical protocols, and usually it's just some extra paperwork and time to get things approved.  

It's undoubtedly frustrating when you have a plan to move forward, but between your doc and the manufacturers I'm sure they will be able to provide the documentation you need to get the approval.  Most likely it won't be the first or last time your doctor has had to educate some insurance company or another... hopefully it will get resolved for you soon.
~eureka

[OC]

I would get a copy of your biopsy report to the insurance company pronto...

[CaughtOffGuard]

I know how you feel!!!  The same thing happened to me.  Luckily, the problem can be solved with fax from your doctor.

I have Humana Insurance and the INCIVEK was declined, then approved later, on the same day.

Good luck with everything!

christina



  

[his3707]

Hey girl, everything will work out.  You have come this far nothing is going to stop you.  Just another bump in the road on the way to SVR!
Lydia  

[Mary4now]

Oh dont the insurance companies just drive you up the wall.  They are just playing games and you have to go back at em.  Your doctor should take them on this one.  I used to bill insurance and you have to have the exact right code for certain payment etc.  I cant stand them.....  just breathe, have patience and keep on..... so sorry you have to go through this.
best luck and healing wishes your way,
Mary

[elpasolady]

You WILL treat!  It's that simple. Now smile and sleep well.
BIG HUG!
Debbie

[Dee1956]

WOW!  I woke this am with a raging headache from my hysterics yesterday to find all of these wonderful supportive loving messages.  I am overwhelmed with gratitude.
You all have brought tears to my eyes with your encouraging words.  I will take a breath and I will tell myself this is a bump in the road and that some idiot at the ins co doesn't realize that all 3 drugs go together.  Vertex seems to be trying to help as well, I had gone to them to help with copays.  I will take this extra time to get my ducks in a row.  
God Bless all of you and I am sorry I wasted a thread on my hysterics.  Funny haven't asked a question in a long time, now I have asked two in the same month.
Thank you so much, my headache is getting better already :)
Dee

[flcyclist]

I agree with the others that this is a major oversight and somebody is dropping the ball with the insco.  This might take hours on the phone with ins, or even better if your doctor calls directly to work this out.  No interferon in this trt makes no sense.

Is it possible they are denying the Pegintron, but would approve Pegasys?  I'm sure you will get this worked out soon.  Best of luck and let us know how it was resolved.

[Dee1956]

I called the insurance co to ask if both Pegasys and Pegintron were covered and was told that it was with a precert which was done along with the doctors notes, results of biopsies, etc
I want to use the Pegasys but I am going to trust my doctors evaluation of me and take what he thinks is best.  He is associated with the Liver Inst in Fairfax Va and is also on the transplant board.  Perhaps he feels that since I tried the Pegasys before and relapsed I need Pegintron to give me a better chance. It is also weight based, perhaps with the 3 drugs it will all be enough to get me to UND, then SVR.   I am going to ask him at my next appt.
Thank you all so much, I don't feel alone now
Dee

[deb121260]

my meds just got approved and the nurse was shocked. she said she has to appeal everyones med all the time because the insurance companies dont want to fork out the money,  they will try anything to not approve.  In the end they end up getting approved.They told me the meds would cost 11,000 a week if i had to pay.  Its crazy. Good luck and they will approve it.

[nygirl7]

Dee it wont really make that much of a difference peg to peg as long as you have a peg in there!  Intron is supposed to be a big tougher but a bit more effective. Who knows for sure though. I am glad you got it straightened out!!!!!!!!

If the pegintron does not get approved for some reason at all go to Commitment to Care they approved my meds when the insurance would not let me extend to 72. All I needed was proof that I was denied-bing bang boom easy as pie.

[frijole]

Isn't there a number to call the insurance company?  Did your denial letter give a reason?  My denial letter for PegIntron said it was because my doctor did not say that I failed Pegasys treatment.  It has now been approved after they submitted the information.  If you can, go on the internet for your insco and see what forms are available.  It could be as simple as that.

My guess is that the Pegasys is cheaper to the insco.

frijole

[elpasolady]

So glad you are feeling better and in power mode this morning Dee.
Just want to add, that when I decided to treat my doctors office took care of all my insurance requirements.  I did nothing and all was approved right away.
BUT, what I want to add is that the Pegasys had to be covered under my major medical, where as the other two were covered under my presription drug plan.  Perhaps that is what's going on.  It was a separate authorization.
Keep us updated!
Debbie

[Dee1956]

Thank you all very much for your support.  I just received a call from the Docs office, the business administrator talked to the ins doc and he has approved the tx.
I am happy and worn out.  It will probably be a week or so before the meds are at the pharmacy.  I feel so much better
Elpasolady, you are right, the peg is under "Specialty Pharmacy" and is approved differently
than the other two because it is an injectable
NYGirl, thanks so much for your response, I remember that you used Pegintron, hopefully my experience will mirror yours and some day I will be here like you, SVR, and still helping people.
Again, thank you all so very much.  It is nice to feel like I am part of a group of caring supportive people.  I don't have much support where I am.  My family all live 8 plus hours away.  Oh the Incivek alone is $20K a month, then adding on the Riba and Peg, that is a lot of money so I guess I can understand the hoops they require one to jump through.  Incivek sounds really great as far as support, they have a 24 hour a day nurse you can talk to.  The nurse I spoke to was very friendly.  It will be nice this go round to have some actual medical support. :)   I am feeling much better thanks to all of you.
Dee

[flcyclist]

Great news Dee.  Must be a huge relief.  So glad this worked out for you.

I'm also using a specialty pharmacy, so be sure you order in time to make sure the delivery is to you when its needed.  I've run into a few problems since every 2 months the specialty pharm needs to reapprove the meds.  Their nurse requires your doctor to send your results for them to review, then needs to follow up with a brief consult with your doctor.  Be sure someone doesn't drop the ball and put you in a stressful situation.  Sometimes the doctors will keep additional meds in case of a delayed delivery, so might be good to discuss this with the doc.  This approval might be different for various insco's.

[meakea]

Awesome news Dee...glad this is an issue that is now in the past.

I have to wholeheartedly agree with flcyclist about the med delivery in the future.  Make sure you are on top of it.  I, and some others, went so far as to get our first shipment of meds and then we waited 2 or 3 weeks before we started treatment.  Then we re-ordered the 2nd shipment as if we had started when the first shipment arrived.  That way, we always had a minimum of 2 week's worth of meds on hand in case there was ever a delay.  I know you are anxious to start treatment but, at the very least, discuss the potential for medication delay with your doc BEFORE it happens so that you know what to do in case it does happen.  Be prepared for every twist and turn to prevent a delay in your meds.  

[his3707]

Yay!  whew!   :)  

[CaughtOffGuard]

Woohoo!  :-)

[orphanedhawk]

Dee,
I just read this and have nothing else to add, other than I'm glad you persevered.

Insurance people should not be making medical decisions! They aren't trained in medicine.
The whole situation is infuriating but you are on the right road now.
Congrats, and stay strong.
OH

[crossroadsec]

Congratulations. And flycyclist - thanks for the tip of reorder. I'm calling for my 3rd refill tomorrow. The 24 hr nurses have been great. I don't use em as much since I found this forum. lol. But I called about 6 times. One of them even gave me her cell number when I was itchy blistery and told me the hours she was on for that week. We txted a few times. Love those specialty pharmacies!
Mine called me w/ my original approval and I was shopping. I sat down and cried like a baby. She was so kind n happy to deliver the news.
Just took that last med. This was a great story to fall asleep with. I'm thankful for your news.. really truly thankful.
Tearfully, Karen :')

[Dee1956]

Thank you again for all of your responses, I am overwhelmed by the kindness of everyone.  It renews my faith that so many people reached out to me.,
I will post when I start
Love to all
Dee

[Dee1956]

Hi I forgot to mention that while I was on the phone with the nurse we had an earthquake here
I will never forget the day I was approved for tx :)

[meakea]

Baaahahahaha, Dee...you moved heaven and earth to get them approved.  :)

[frijole]

DEE
shake rattle and roll and start tx!

There is a nurse coming to show me how to prepare the PegInton today.  Like you I did the Pegasys before but the doc wanted to use the other due to relapse.  At first I said no, but since you have to mix it .... anyway she is coming with a dummy kit to show me how to use it and I will start Friday with the real deal. Woopee.

I am so glad your crisis is over.  Ain't this anxiety the pits?

frijole

[Dee1956]

Frijole, yes this anxiety is the pits, it has taught me not to get so upset when things don't work out the way I thought they would.  I like that "shake rattle and roll" very funny,  Thanks for letting me know that you decided to stick with the Pegintron. for whatever reason I am afraid of it but have to trust my doctor to know what he thinks will work best for me.

Meakea, like your "moving heaven and earth"
Thanks again to all
Dee

[frijole]

Dee
The nurse came yesterday and gave me a lesson on the redipen.  I didn't think I needed that but am really glad I had it.  I asked her and from her experience, side effects are similar to Pegasys.  Now, that is contrary to what I have seen in forum.  The edge does seem to be to Pegasys, but since that didn't work, I am fully willing to do the other.  Tomorrow is the day for me.
frijole