insurance co denied meds

I had blood work done and had posted results here a few weeks ago, then the Dr. office called and wanted me to come in, they prescribed Aransep, Neulasta and wantd more labs done in 10 days.  While waiting for my meds to be authorized I had my blood work done.  The day after labs I called my Dr. office to find out about meds, my insurance co said they would only authorize these two meds if i was in kidney failure.  My Dr. then tried to get the generic brands of these meds authorized and my insurance co denied my meds again saying I had to be in renal failure for these types of meds.  That they consider these meds experimental for chemo and hep c patients.  This is such ****!!!!!!!  They want me practially dead before they are willing to give me the meds.  My Dr. says we can stop treatment until my counts go up again but that doing so will drastically decrease my chances of being cured and may also extend my treatment from 6 months to 1 year.  Im not really sure why we pay of health insurance when we can't get the meds we need!  What a waaste of money!!!!!!!!  Sorry about venting but damn I'm angry!

Best wishes to all, take care!!

[desrt]

Did you try calling Amgen's Safety Net program? I listed the phone #s on your last posting.

[gizmoesgirl]

No I have not yet i was waitn for my Dr to call to get info on what he prescribed before I called. Although, I don't thiink I will qualify as I have no qualified for any assitance from any of the drug companies, they say that because of my insurance coverage I don't qualify.  LOL what a joke!!!!!   If thats not a doub;e edge sword I don't know what is!!!!

[Bill1954]

Call your doc’s office tomorrow and see if they can somehow change the ICD-9 code to include chemotherapy. I’ve never had to deal with this personal basis, but I understand that occasionally insurance coding is very sensitive to this sort of thing. Perhaps ask to speak to the person/ entity that performs the insurance coding… they might have a better handle on this than your physician. Additionally, call the Amgen line that Desrt referred to.

All the best,

Bill

[ladywhy]

I can't believe this. I posted to you last night and it's gone! Get a letter from the ins. co. stating they are denying you coverage for these meds...keep a copy for yourself  (for legal purposes) and either you or dr.'s office or both get in touch with the manufacturers...they may very well donate.
I and many others here have had issues with insurance...but somehow we got through it...and you will too.
Keep in close contact...let us know how you're doing.

Hugs
Yvonne

[GrandmaA]

Some of these medications are extremely expensive. You need to keep after the insurance company. I don't think the drug companies will give them away when your insurance won't pay for them but you can ask. Do not give up. It's terrible that we have to fight the virus and the insurance co. at the same time when we have no energy and we need the meds. My heart goes out to you.

Adie

[gauf]

I got the same problem, got a letter of denial for the peg from my insurance co. Got the doctor working on an appeal letter. Delays, delays.......

[Bill1954]

You're not loosing your mind... at least not here :o). I think this was posted on both sides, and you responded in social.

Bill

[ladywhy]

Bill:Thank you so much!
I need constant reassurance that all is not lost..lol

GrandmaA: You'd be surprised...it's a major tax write-off for them. What they charge and what these meds actually cost them...let's just say they make a nice profit. It is a benefit for them as well.
Good to see you here...how's the water colors coming along?

Worth checking into anyway....

[HARRYBEADS]

In the last quarter of my 48 week treatment for 1a, my red cell count was below 100 and it started at 170.The Docs didn't want to give me procrit or any booster,the only recourse was to drop one ribavarin pil per day. In a week it was up to 120and stayed that way till the end of treatment, that I cleared.

Harry

[orphanedhawk]

Insurance companies will resist paying out if they can get away with it, I'd phone them and threaten to file a lawsuit. Be clear, firm and angry. Tell them you need these meds as decided by your doctor not by some insurance paper pusher. The squeeky wheel gets the grease.

Secondly, I got neupogen for free because I have no insurance and my doc was willing to help me out. Ambien has a program in place, You have insurance? What if you drop it? Then you don't.

Good luck and please let us know how this progresses.

[merryBe]

well, I've been so sick I've not been in here much this month, but I'm glad I saw this!!!!!

that is just diapertime aggravation.....
.but I wouldn't quit.
Don't you quit!!!!!!!!

I've actually called and gotten results asking to talk to the nurse that approves the medicines (yes for every company there is at least a nurse (why not a doc??) looking over the notes of all those claims incoming.

Make sure you ask to talk to the approval person NOT just the initial staff person you get when you call for perscription help....ask for THE NAME of the person in charge of approvals.

then, if all else fails, and I mean, IF the docs coded right (as above, and IF the doc sent in all their ffice notes and labs (as required) then I would politely ask for the number of their legal department before you get off the phone.
Don't make it a threat, just be very matter of fact. "My brother is an attorney and instucted me to obtain the contact numbers and addresses today"...(or my sister)
(heck I'll be that sister)   but don't give up.....part of the problem is people do not get on the horn and advocate for themselves. They think a denial is final.

It took me 20 hrs on the phone for ONE drug last month...due to a doctor screw up.
It took me 5 hours on the phone last week for my INF/Riba.....in this case I am an exception in that my case normally would have been denied but being a wolverine polite but persistant paid off.....but denials are reversed regularly when doctors or patients, or both advocate for themselves. (PS. even if you get voice mails, leave messages and call at least twice of 3 times a day until somebody does get back to you.
remember, wh are they going to provide for...the one that accepts a denial...or the one who does not.........3 guesses.

Do you mind sharing which insurance you have??

hang in there

[gizmoesgirl]

Thanks for the great advice and suggestions.  I have contacted my doctor to verify all the correct info was sent to the insurance co.  Indeed is was sent and has been sent two other times to verify that they have all the correct info.  The insurance company states that for Hep C patients and Chemo patients, Aranesp and neulasta are experimental drugs and my coverage does not cover experimental drugs.  The thing that blows my mind is that they would rather wait until Im hospitalized and need many many more meds to make me better than just authorize the meds now.  That to me makes no sense.  Also, I was waiting on my nurse to return my call with the info for the Aranesp (for dosage purposes) so that I could call saftey net from Amgen.  The nurse told me not to call them just yet that they were still trying to get another med authorized by the insurance co.  How long should I wait?  Should I call anyways?  It has been 4 weeks already, this is absolutely crazy, I feel like **** all day every day!!!!!!   I want my life back!!!!!!  

[merryBe]

it's not very funny is it.
My NP said she had more success getting amputations approved, but not the insulin that would have prevented the patient losing the limb.

4 weeks is long enough, but every month you are denied saves them a thousand bucks.
Take a new draw if you haven't...some people will spring back on their own....as the marrow starts kicking into a higher gear on its own...if that hasn't happened.
I would call Amgen, definitively....but I'd still call the insurance and take first and last names..like I said before..

[gizmoesgirl]

They have taken two seperate labs since the drop in my counts and they are still dropping.  They are not dropping drastically but still dropping.  This is why im so concerned.  Kidney failure sounds like no fun and I do not want to add it to my list of issues right at the moment!   I am going to call the insurance company tomorrow as they are already closed today.  Thanks again for the advice

Take care

[Bill1954]

This may have been mentioned above already, but it’s important so I’ll take a chance on repeating it;

Ask your doctor if the Arenesp can be replaced by generic EPO, and Neulasta replaced by Neupogen. You might even call your insurance company yourself and inquire if they will approve EPO and Neupogen over the other two. They all serve the same basic function- by boosting bone marrow production of red and white blood cells. You’re doctor has chosen to prescribe some very pricey recent versions of these meds. Keep at it until you get there,

Bill

[gizmoesgirl]

Great news...after two apeals with the Insurance company the finally approved epogen.  the down side to that is that it is not Aranesp.  I will have to take 3 shots a week of the epogen verses one shot a week of Aranesp but at least I will hopefully start to feel better and be able to function some what.

Thanks ro everyone for the support!!!

Best wishes and take care

[Bill1954]

Congratulations on a job well done! The Epo should make this a much easier trip for you. What is the status on the Neulasta/ Neupogen? Are you making any progress on that front?

Good for you for sticking it out; I sometimes think insurance randomly denies in the hopes that a percentage of patients won’t appeal. Why not, if it works :o)?

Take care,

Bill

[gizmoesgirl]

No neulasta/neupogen yet...still trying for that!

Thank you

[nygirl7]

I was denied to extend from 48 weeks to 72 weeks from my  insurance company - once i was denied Committment to Care paid for EVERYTHING.  Their patients assistance program knew I was insured but it didn't matter a bit. As long as you have the piece of paper saying you were denied the meds - they should cover the cost for you.  Fully.

I do not understand why you will be taking three shots a week.  I was on epogen - 80,000 a week and my hemo soared too high doing 40,000 x 2 a week.  We had to space it out to every five days to keep me in a reasonable place.

How low is your hemo?  Most people start once a week and then if that does not help they go up to twice at 40,000.  if you are doing it three times a week that's 120,000 and I've never heard of that before - the epogen carries it's own black box warnings to I'm pretty surprised any doctor would write a script for that much a week really.

Most of us have taken the epo or procrit - it's very rare that anyones insurance covers the Arenesp. The epo is worth $6,000 a box. it only has ten vials and if you are taking it 3 times a week it would only last three weeks.  That's why I'm kind of wondering if you got that right.

[gizmoesgirl]

Im not sure what my latest hemo is but my previous blood work from 6 weeks ago was WBC 2.5
RBC 3.46
HEMOGLOBIN 11
HEMATOCRIT 31.3

I have not got the copy of my last lab work which was two weeks ago but the nurse called to let me know that my counts had dropped again and that they were still trying to get my meds approved.

My Dr said that I will have to take three shots a week (mon.,wed.,fri.).  Im not sure why they are prescribing that much but that is what the script was for.  I was not informed about the black box warnings.  What are they?  Should i be concerned?

Take Care