how to get insurance approval for rescue drugs

How does a doctor get approval for the rescue drugs. I've been told they are not approved for use with hcv tx although they used all the time. If your numbers improve because of the rescue drugs, then there seems to be a problem proving to the insurance company that you still have neutropenia or anemia.
Thank you

[child24angel]

If your numbers improve then why do you still need the
rescue drugs?

My son was given procrit...until his HGB improved..then he
was taken off.

I have no idea how to get the doctor to get approval.  
BEG? :)

[spectda]

Hi Elaine, my numbers haven't improved much, anc goes up really high a couple of days after neupogen once as high as 6.5 (6500). Once I was late for an neupogen injection because I forgot it when I went away and it was at .3 again just being a couple of days late.

I just wondered in general how the doctor handles getting these drugs approved. Many people have treated and kept taking procrit to stay at 10-11 hgb throughout treatment. The issue isn;t when it an emergency, the issue is continued use to keep you blood cell levels adequate

I hope you are doing well,
Dave

[spectda]

Sorry about all the grammar mistakes, typos and misspelling. I'd like to blame it on treatment, but I can't remember if I was any better before. Luckily people generally know what my intent was! LOL

[pcds]

When my WBC went low my auth for neupogin was for a year.  I would think if you have an abnormal blood value, it would qualify you for drugs.  My WBC improved with neupogin, but it was needed to stay there.  When it stopped my count went down.  The same should hold for procrit.  You get it because of you labs, if you stop, and labs go down, you need to stay on it until your doctor says you don't.  Not sure how often a doc takes you off the helper drugs to see if you are OK.  For me, I assumed I would need the neupogin the whole course of tx.  I don't know about procrit.  Doctors know what to say to get meds covered under insurance.
Judy

[RobertBeWell]

Well, I can't comment because it hasn't actually happened, but I am starting tx in a couple days in a trial. I went to my PCP and talked with him about this very issue. He asked me for some paperwork describing the study, and put it in my chart. This way, he says, if and when the need arises for any other medication, the study doctor just needs to send him a "consult" recommending whatever is needed, and he will prescribe it.

He doesn't see any issues with insurance paying. I got the impression that adding the study records to my chart put me in a good place as far as insurance is concerned. I'm pretty lucky though - I have a great insurance company. I don't think they have ever questioned a single charge.

Perhaps this route might work for you too Dave - getting your primary care doc to do the prescribing.

Robert

[RobertBeWell]

"Doctors know what to say to get meds covered under insurance. "

Yes, they absolutely do. And if you have a good primary care doc, s/he will go to bat for you big time.

[spectda]

My study doc always responds well and handles anything I need. I have absolutely no complaints and have been treated very well and carefully. i was just wondering what the approval process was since it seems to be taking my insurance some time to approve my refill on the neupogen. I am sure it will all get resolved in the next couple of days.

[mountainair]

Hy Dave,

My study doc has been going through the multiple appelas process with my prescription drug insurance CAREMARK CVS/ Blue Cross of CA who keeps denying the neupogen.  My ANC went below 500 last week.  My Treatment coordinator for the study said the Study won't provide it and insurance comapnies "don't want to pay for it" but there's no alternative other than another dose reduction or discontinuing treatment.  She recommends that I pay for it out of pocket, but it's VERY expensive.  She said it's $300/shot, but my pharmacy said it costs $1200.  The Study Doc was supposed to call me today with the results of the Appeal, but they didn't call, so I called the insurance and they said the Doc has to file a second level appeal and ask for a "peer to peer review", but they may deny it again.

I've already been dose reduced on both the riba and the IFN, but the ANC keeps dropping.  I am really worried that all my RVR and UND since wk 6 will come to nothing but treatment failure due to my inability to fund a rescue drug.  I thought the Study consent forms said that the Study would cover "all study treatment related medical treatment" but now they say that discontinuing treatment is what that really means!!?

Who is your prescription drug insurance provider?  

Has anyone been able to get the neupogen approved through CAREMARK CVS?

Any help is greatly appreciated!

Lynda

[spectda]

Hi Lynda-

Usually the study will not pay for rescue drugs which are not the same as treatment drugs, and which are not needed by all participants. The exception would be if they were studying the rescue drug as an adjunct to the treatment drugs.

I was happy to hear today that my neupogen was just approved for the second time by anthem blue cross, my doc knew how to handle it as Judy and Robert mentioned he would. There was no question of medical necessity.

My guess is that if your anc is below .5 it will be approved. I paid for mine out of pocket the first time, and then the pharmacy reimbursed me when the approval came through because I needed it asap as you most likely do too.

Good luck, I think it will work out for you also, because the insurance company doesn't want to pay for medical attention that may be necessary if you don't get the neupogen.
- Dave

[nygirl7]

At first I had trouble getting mine approved. The woman at my local pharmacy kept trying different tacts to get it through ordering it as Procrit didnt work but ordering it in the generic Epogen helped. And instead of two shots a week she put it in as a month supply and then it all went right through. Epo costs like $6,000 a box so that is why they make it so hard.

While I don't know much about neup - I think it's the same sort of thing once you can get it to go through they'll keep giving it to you (I was on epo for 69 weeks).  Once in awhile they would have to prequalify it or whatever they called it but it always went straight through the doctor just had to write a script for me.

[FlGuy]

I liked the idea of a hematologist.  In first tx I started the process by visiting a nearby oncologist/hematologist.  The GI steered me there and both docs actually communicated with each other.  Thru both treatments I needed both white stuff and red stuff.  Going in about every two weeks, the hema tech would run a cbc, they had a cbc machine which would spit out a full report right there.  Then, they would dtermine if I was a quart low.  If so, they would shoot me up right away.  In and out in about 10 minutes.  In addition to the instant response, was the fact that it was in a clinical setting - no prescription required.  With no prescription there was no pharmacy. Since it was a clinical setting it was applied against medical, not prescription coverage.  No out of pocket other than the co-pay for the office visit, which was pretty cheap.  I only needed to go to Quest for VL and Liver Panel and that sort of stuff.

[FlGuy]

I am told (not absolutely sure) that since it was a clinical setting that levels for intervention were at the discretion of the doc, not predetermined by a pharmacy chart. Which, I think, is why we were able to target hgb level between 10 and 11.  So, there there were times when I got Aranesp at 11.2 - catching a falling level in advance.

[mountainair]

Hey Dave, thanks for getting back to me.  I also have Anthem Blue Cross for my medical, but my company has separated the prescription drug coverage which is now CAREMARK CVS.  A coup[e of times now I have gotten caught in the middle.  I had to pay out of pocket for procrit once when I hemhorraged after surgery because the CAREMARK denied procrit and told me I should just get another blood transfusion (which Blue Cross pays for - not them!).  Today I will check with my treatment coordinator about the second level appeal.  How much did you have to pay up front?  I am just trying to find out if its's $300 for a shot or $1200.

[mountainair]

Thanks for your input folks.  Does anybody know what it is the doctors are doing to get the neupogen approved?  Either my Study Doctor doesn't know how to handle it or else the Insurance company is just really being obstinant.  If I can get the $$ together, I guess I will pay for the first shot to see if it helps.  I want to get thru this and get back to having the energy to do the physical activities I love.  That's the mental image I'm holding onto!!  Lynda

[FlGuy]

If energy is the problem, Neupogen is probably not the answer.  If you are on treatment and gassed/fatigued it's more likely hemolytic anemia.  If that's the case the more likely solution is Procrit/epo/Aranesp

[spectda]

Anthem is not the easiest company to work with. It sounds like your situation with the two companies certainly makes it tougher. When I got my neupogen i purchased one injection for $550 on my credit card while they sorted it out, by the next week they had reimbursed me and authorized the further injections.

I think the system FLGuy had was a good way to go, but we have less options in a trial.

I'll bet your trial doc will get the meds for you though, I really hope so. We don't need the added anxiety while treating.

let us know how it works out,
- dave

[spectda]

I think actually that it was $300 per injection not $550 but I am not sure and I can't find the receipt right now.  Call your pharmacy and they will tell you the retail cost. The only issue is that you may have to find a pharmacy that has some in stock. I think they have to order 10 vials at a time, and they don't want to order them without knowing you will take most of them. My prescription is for 7 vials each time it renews.
Good luck,
dave

[mountainair]

Thanks for your responses! Severe loss of energy was the reason I finally sought hep C tx via a clinincal trial.  You're right that the tx anemia has been a real challenge, but I am in the bocep anemia trial dose reduction arm so I am not allowed to use procrit.  The doc has been increasing and decreasing my riba every 2 wks trying to keep my hgb no lower than 10 while keeping the riba as high as possible.

[mountainair]

Hi Dave,

Yeah, I called the pharmacy last week - that's why I got confused because they said "a four day supply" was >$1200.  I wonder if that's 4 shots which would be a month's supply w/ weekly injections.  I'll call them again.

[spectda]

I am sure this will be for 4 vials, a four week supply. My guess it that your doc will have you take one injection per week and see how you respond. They have to order it in that manner to get it approved by insurance.

[mountainair]

Got ahold of the insurance co and the tx coordinator - both say they are waiting on the other, so I gave the doc the appeals dept. phone number.  Then I called the pharmacy and they said one shot is $642.00, so I guess I will get one and see if it helps while the ins co & the dr try to get together on the 2nd level appeal.  They've been screwing around with this for more than a week, so my blood draw is Monday, and the tx coordinator says if I don't get the shot by tomorrow that I shouldn't take it until after Monday so it doesn't screw up the labs with alarmingly high WBC values.  Geez, I am so tired - I know - I know - there's no crying in baseball - I mean tx....  We'll figure something out eventually.

[nygirl7]

IF you have to pay for it and then it's approved can't you get the money back? That is what usually they do at my pharmacy - if it's within a month they will usually take the insurance and give you the $$$ back.

Tell that doctor to get his butt in gear and get this approved it's so not right to screw around like this (I know they are busy but.....).

Hoping it comes through very shortly. I'd call that doc and tell him that i was going to pay over $600 out of pocket for it - try and play on his sympathy maybe?

[spectda]

It sounds like a good plan. Get the vial and take the injection and insure the pharmacy will reimburse you later if the insurance approves which it probably will. At least you will not have to worry about your anc. The neupogen works very quickly.

I am sorry about all of the trouble you have had. I certainly can relate!

You have a good attitude considering everything you are dealing with. take care of yourself,
Dave

[CoWriter]

Your doctor can get it approved by using a DIAGNOSIS CODE of "chemotherapy" instead of "hemolytic anemia".  It's a loophole.  Interferon is considered "chemotherapy" and Procrit is indicated for anemia caused by chemotherapy.

That's why some hepatologists send patients to an oncologist or hematologist when they need Procrit.

Co