Insurance denied my retreatment

[rawhide]

hi again,
I posted last May and got great help, so here I am back again.
Facts: Hep C, type 1A with liver damage 3-4, completed 48 weeks of Pegintron/Riba in Sept 06.  My biopsy improved to early stage 3.  The bad news is I never cleared the virus by the more sensitive Hep C test.

My doc and I agree it would be worth a second try since I missed a week of dose during my first 12 weeks.  After a letter from my doc and calls (not returned) from me my current insurance company is refusing to pay for the drugs.  

I am not sure what to do next...(it is so weird to be fighting for drugs I need but really dread).  Anybody run into this?
Hope all is well with the fight you'all are in.  
Rawhide/Laura

[Kalio1]

It just amazes me! LOL Who knew all I had to do was check an internet forum of people I don't know to learn the "facts" of my life. I could have sworn this forum was about this disease we all are fighting. This soap opera stuff is the result of some type of internet addiction issue I am afraid. I think for some it becomes their whole social life and becomes far more important than their "real" lives somehow. Not much different that hiding in a bottle of booze. It's just a different type of hiding. I don't know, but I imagine there are lots of therapists dealing with this "new" phenomenon created by the net. For me, in spite of that downside, this forum has been a life saver. I am a very high energy person and have been rendered very ill by these drugs so it has given me an outlet, a tool to cope with the long days that stretch out before me. I have learned an incredible amount about Hep C and many other subjects lying here, thanks to the internet. Im sure it has kept me from falling into the black hole of depression. Having a world of information at my fingertips has been my saving grace. Interacting with others with this illness helps so much in making you feel the "lonliness of disease" much less.

I try to remain removed from it and compassionate to those clearly suffering from this type of disorder but ongoing attacks do wear on you and set a negative tone to the place. It really is a "tragedy of commons" situation where each participant has to take responsibility for what they contribute or things go sideways and the "real" job of aiding those with this disease and sharing information and ideas gets lost.

I know you have spoken before about raising kids in a priviledged area and the pressures placed upon them from that enviornment. I can definately relate. Money is all smoke and mirrors, if you are a jerk you are a jerk be you rich or be you poor. If kids learn that lesson, they are way ahead in the game of life and I am sure you taught yours well. How much money you have is a poor measure of character and to me, character is what really counts in life. How much of that you have banked is worth all the gold in the world. When it comes to character Debby, you are a wealthy woman.

[NYgirl]

Do you not understand that I LIVE IN THE RICHEST TOWN ON THIS FORUM???  DAMN GIRL - STOP PRETENDING TO HAVE MORE MONEY THAN ME...YOU KNOW FOR A FACT IT'S ME i AM THE RICH ONE!!!!!!!!!!!

;)

hahahaha.

Well...I may not be Oprah's best friend like YOU but...President Clinton lives one town down and I bet if I spend $20 on a cigar I can make good friends with him?



Oh this board just kills me with pettiness sometimes.

Kalio - please send me diamonds, asap. Kalio - since you are so filthy loaded wealthy that nobody can't stand it will you buy me a house in Santa Barbara too?

;)

I love you girl. Just trying to make you smile. :)

[jmjm530]

Reminds me of some of those headlines at the Supermarket Checkout Counter papers. It's Mr. Jones' turn to take his daughter to school that day. He's spotted by reporters kissing his wife goodbye as he leaves the house.

The headline reads:

MR.JONES SEEN WITH A YOUNGER WOMAN AND LEAVES WIFE.

Hey, you gotta sell papers :)

[jmjm530]

Sorry Laura. Two suggestions. First, continue pressing with the insurance company. Call, call again, and always ask to speak to a supervisor. And if they can't help you, ask to speak to the supervisor's supervisor, etc. Make sure to ask what the "criteria" is for re-treatment. Maybe they need a certain kind of note from the doctor (or doctors) saying certain specific things. Or, maybe they need some sort of documentation. In any event, find out what they require and then get it to them. Think of an insurance company as large maze with someone in the center who can help you. Your quest is to find that person and it  may take numerous attempts.

If this doesn't work, or as an alternative, contact the two drug companies at the drug assistance help lines (I'm sure someone will post the phone numbers soon) and apply for free drugs. There may be an income requirement but I hear it's flexible. My uderstanding is there's no asset requirement.

All the best moving forward.

-- Jim

[Kalio1]

I'd apply to Commitment to Care ( if you are using PegIntron) or Pegassist.com for Pegasys.
C2C phone is 800 521 7157. Pegasys has a website with the info @ Pegassist.com.

Very generous qualification standards. They ship the meds to your door. You will need a scrip. Your doc office can supply them with the info.

Take care, let us know how it goes.

[NYgirl]

Laura,

I was denied extending treatment meds by my insurance company (I am going to 72 weeks) and I did what Kalio has advised and called Committment to Care. They were prompt, easy and FREE and they send the meds right in the mail to me.

The insurance company does pay for my Epogen (so far) but even if they start refusing that one - most of the companies now DO have programs to help us out.

And the good news is you really don't have to be a pauper - they allow you to make a living and still approve you.

I think that they would definitely be worth a try!

[FlGuy]

If your iinsurance is a benefit of you employer you might try hunting down 'a benefits specialist' who may be able to give you some backgrsound or requirements for an appeal process.  Sometimes insurance (not just medical) give an initial 'no' hoping a claiming person will just go away.  Stakes are to high for you to take a 'no' without a fight.

[can-do-man]

Closing in on 48 weeks but need to extend, after the fight with insurance on procrit my hepatologist is dealing with my insurance for me since they saw it his way on the procrit.
My question is just in case i called Commitment to care at Schering but was told that besides your income you have to have spend it was either 3 or 6% of your income on prescription drugs for the year before the drugs were free. I've had 2 different people there tell me this. Has anyone else been told this? So i quess if insurance refuses to extend i'll just bye a months supply of the meds, and fill my others at the first of the year too. Doc will keep me going till then.

[TatorToT]

I would suggest talking to Kalio about this as she comes off pretty well ta do but managed to qualify for the Commitment To Care... so she may know more on this, but My only problem with it was that it takes a min of 2 weeks to process, & with all the pre-qualifications I did... I syill hit mega snafoo's!!!
:)

[imbetternow]

Can I ask who your insurance company is? Coventry?

Infergen has something called the Aspire Program. Valiant is the Manufacturer. Try those people

[Kalio1]

I think your comment about me "coming off as well to do" was offensive and perpetuates a myth a certain clique of people have created about me here. I met my husband in Greece because as a young woman I scrimped and saved to take a trip to Europe and I live in Santa Barbara, the town I was born in in an old house. From these scant facts, gleened from over a year of visiting here, this BS about me "coming off well to do" was born. How petty is that? Some personal info does get shared here, apparently if I had been born elsewhere and met my husband in St. Louis you would have pidgeonholed me differently. It's absurd.

Anyone could do the same thing to you or others here. You talk about travelling and various other things that I could use as fodder for such judgements and then go around perpetuating those myths about you, accuse you of "bragging" for talking about vacations you have taken but I think it is judgemental and inappropriate so I wouldn't dream of doing such a thing to anyone, especially strangers I know nothing about.

[jmjm530]

It's a shame you even have to explain yourself, regardless of your financial status. But I saw those posts as well where things were twisted and turned. Gets to the point where you're afraid to say anything personal here. I mentioned while on treatment I was too sick to work. That got translated into "some people have too much time on their hands because they don't work". I had a really rough time with tx and discussed my symptons in detailed. Some started calling me a "whiner". Get real, this is supposed to be a *support* group.

Frankly, I think it's the people -- and I'm not addressing this to any one person, especially Tator since I really haven't followed her previous posts -- who file away these personal tidbits and use them against others that have too much time on their hands. A NUMBER of people here have offered information that CLEARLY suggests they are well do do -- not in an offensive way, but just straight out. So why is it that only Kalio got attacked in that regard? Being well to do isn't a crime, not that anyone here actually knows what Kalio's financial circumstances are as evident by a post she really shouldn't have had to make. It would be nice if people stopped taking pot shots at Kalio, or anyone else here for that matter. Sure, take pot shots at ideas expressed, but not the person. And not the house they live in, or that we think they live in.

-- Jim

[rawhide]

Nice to hear back so soon on my question.  JMJM, you are right about the insurance maze...so far I have been unable to have a talk with a living human when I call.  
Thanks for the info on other options.

I did get a letter of denial and it said I didn't meet the criteria for medical necessity....They don't approve retreatment if you failed previous regimen of pegylated interferon.

History of bld test..I had 3log drop at 12 weeks, quit my 1st doc who was naive at 24 weeks, at 28 weeks my Quant RNA =undetected(below 615) and my Qual TMA at 30 weeks was detected.
I stopped ribavirin and have continued on with Pegintron as an antifibrotic.

Laura

[can-do-man]

Don't come here much anymore, Just thought i had a simple question since i've seen it talked about it alot. Guess nothing is simple here anymore....... Oh Well

[jmjm530]

CDM: Guess nothing is simple here anymore
----------------------------------------
You mean the Creme de Nuit days? Hey, howza it going partner? Why don't you post this tomorrow for NYGirl, as she doesn't log on at night. I believe she's gotten drugs from Shearing and didn't mention anything about a per cent of income. How many months short of meds are you and what do you need? Sometimes folks here have extras. I had some myself but recently turned them back to my doctor as they were about to expire soon.

Be well.

-- Jim

[can-do-man]

Im not short on meds, and if my Doc can't get the insurance to extend, (And they haven't said yet they wouldn't) My Hepatologist told me they have enough at the hospital to keep me going till we get it strighten out. He had gave me procrit till the insurance saw it his way after telling me no. Not really a problem as i will just pay cash at the first if i need to. At the cost of these meds that should take care of any % for the year. It was just i was curious as i've never seen anyone on it here say anything but your income level.

Could have my doc write me a scrip for that cream de nut. That ought to push me over the top.  :o)

Hope your doing better post tx. Take care

[jmjm530]

cdm: Could have my doc write me a scrip for that cream de nut. That ought to push me over the top. :o)
-------------------------------
LOL

[Kalio1]

I hope you are doing well and aging in there. Nice to see you.
I have not heard the percentage spent on drugs requirement before from C2C. I would think your copays on meds. in a year would qualify for that 3-6%? I am on their program so if they have implemented any additional restrictions it would affect new applicants but it wasn't a requirement a year ago when I applied.
If true, that indicates they are trimming down on meds they are giving out by adding new restrictions. I wonder if that is due to an increase in applicants? Did you hear that from Commitment to Care?

[can-do-man]

Thanks, might be something starting at the first of year, just called my NP to see if she knew and she said yes for year 2007 i would have to pay a % of income on prescriptions before they would cover them, but they will send you a months worth free.
So who knows, not going to worry about it. At 5 and 10 dollars co-pay for regular meds it would take all year. So if insurance won't extend at the first of the year i'll pay for a months supply of both. Then won't have to worry about it the rest of the year. Still comes out to a good deal.

[can-do-man]

And yes i called 2 different times to Commitment to Care and was told that by 2 different people. My Doc had told me just in case insurance says no to check into it.

[jmjm530]

rev: I have cameras, recorders, devices shipped out in Pegasys vials.
-----------------------
Well, the new season of "24" should be starting soon. I don't know if you're a fan, but it helped get me through my Monday nights of treatment. Good luck with your file. I don't even know where I put the rx for some new blood tests my doc gave me today. Be well.

-- Jim

[jmjm530]

LOL. BTW just started watching the show recently. I think I may have to get the old DVDs to get things in context. Seems like a real "trip" as they used to say.

[MissMiss]

I think we all three pushed post at the same time!

[MissMiss]

Did your ins. give a reason?  Did you get something in the mail?  Curious which pcr the virus showed up on, EOT, 1 month?

There is always the program where the companies give it to you.  Others who used it will post soon.  Hang in there.

miss