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Insurance

I was wondering if anyone here knows anything about insurance coverage.  If an HMO does not cover a brand name do they have to have an other option.  We are still fighting the insurance company.  It has been over a month.  I know that we have time, however, my husbands cirrhosis is 4 out of 4 on the biopsy.  He had no cirrhosis 3 years ago.  How soon dose it turn to cancer?  I keep running into walls trying to help him.  I feel so helpless at times.  I am use to being able to help him with any of his medical problems.  Last year he had his hip replaced and I had to fight the insurance company about covering the PT.  Point is I am use to it, but this time I am getting no where.  I have already contacted the manufacturer of the Pegasus.  No help yet.  This has been and seems that it will continue to be a long fight.  HELP... any information is greatly appreciated.
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Avatar universal
also less than a year ago he had an ultra sound of the liver that showed normal size and no spotting.  Could he have had cirrhosis and it not show up?  Or does it rappidly be worsting and time be a factor.  Sorry, just so lost.
Avatar universal
i'm so sorry to hear of your problems with insurance...i think you need to be the squeeky wheel. the key is to talk to the right person. on our hmo i talk to two diff people and get two diff answers. you must talk to someone who is above the average clerk...ask to talk to thier manager or something. i hope you can find someone who wants to look into it.

have you tried to get him into a study yet?
Avatar universal
i also am battling insurance company for approval of treatment. they haven't said no...they just haven't said anything at all. they blame it on the dr's office not sending proper info. believe it or not, dr didn't send bx results, VL, or LFT's. now, what could they be thinking. wouldn't that be basic information? was also told today that some ins co drag things out, hoping we get frustrated and give up.  what is suppose to take 3 days has now taken 16. but i am more stubborn than either dr or ins co and will continue to make my daily phone calls...just for their aggravation if nothing else,lol. maybe they'll get sick of hearing from me and give me an answer.
Avatar universal
I share your frustration with the insurance companies. So far I've been lucky in that they've covered everything I've asked for but rarely the first time. Seems like everything has to be pre-certified by the doctor's office, and in a very specific way.

It used to go like this: (1) I need drug so-and-so and the doc writes an rx; (2) I go to the druggist but he says I need a pre-cert; (3) I call my doctor's office and tell them I need a pre-cert; (4) My doctor's office calls me back and tell me that the insurance company won't give me a pre-cert for this particular drug. Period. (5) I go riba-crazy LOL and call the insurance company; (6) The insurance company tells me that the reason they didn't authorize the pre-cert was because the doctor's office didn't give them information that fufilled the *criteria* needed for the pre-cert. (Criteria that only the insurance company apparently knows. LOL.)

After a few rounds of the above, it now goes like this: (1) I need drug so-and-so and the doc writes an rx; (2) I immediately call the insurance company and find out what, if any *criteria* is required for this particular rx. This they willingly give; (3) I call the doctor's office and give them the criteria; (4) The rx goes through. Occasionally, I have to set up a conference call between the insurance company and the doctor's office and get them on the same page. It's really too much work. LOL.

In regard to the ultrasound. An ultrasound is not definitive for cirrhois. Only a biopsy can tell.

Sorry about your husband and I hope everything works out.
Avatar universal
lovingwife:  I am so sorry to hear about your situation with the insurance. You sound very level headed and have been through this maze before so keep your spirits up and you WILL get the help you will need.  My situation may or may not help shed some light?: my doctor called in my prescriptions to a specialty pharmacy he usually uses for his HepC patients and my insurace finally called back after 3 LONG weeks and told me they would not cover it.....panic on my end....I then pulled myself together a day later and called the insurance company and they simply explained that the pharmacy was not under their "umbrella" or wasn't part of their contracted pharmacy plan.  I wish they had just told me that clearly to begin with! So I DIRECTLY just asked what pharmacy they did contract with for those medications and I was told one out of my state of Georgia!  They did tell me that they would contact their "in-network" pharmacy that deals with these drugs and days later I did get a call from this specialty "approved" pharmacy in Florida and they were very helpful.  So my doctor got a call from me telling him they had to re-submit the prescription to the contracted pharmacy in Florida which he did and within 5 days I was approved.....not without MORE gray hair and lots anxious moments ontop of my Hep C symptoms and fears!  I would also take note of jmjm's great diagnosis of the insurance game and ask them directly what "criteria" they need or were missing point blank.  It may be a similar situation as mine where it was just not the right pharmacy being pursued by my doctor's office. Good luck and best to your husband with this battle.

nyhepc:  Sorry you too are still in limbo waiting on the insurance to respond. Is this the same doctors office that you were not pleased with a few weeks ago? Correct me if I'm wrong but I recall your doctor telling you he would stop treatment if you were still detectable at week 12 AND wouldn't help you with Procrit or Neupogen?  If this is the same office you may still want to re-consider contacting another doctor like Albany Gastoenterology as rearfang suggested. They should have presented all the labs with your diagnosis to the insurance company to help with this approval process.  If you stay with that doctor you will most definately have to learn to be the "squeeky wheel" to get the oil.  Good luck and I'm hoping this all works out for you soon.  It is alot of burden to not only carry this disease and the fears and decisions that come with it but to also have to fight your own battles with the doctor and insurance is terrible.  
Good luck to you both, keep your spritis up...things will work out. Scott
Avatar universal
The above are so right about being a squeaky wheel!  It took me 13 months to get some labs paid.  I talk to the insurance co in one state, but the lab can only speak to another rep in another state, I cannot retrieve the info the ins co wants, it must be done by the docs office.......you get the pic.  Ins co states "pre-existing".  No lapse of insurance and I did give them a "certificate of certification" from the previous ins co.  All in all, I began to document names, had riba rage on one clerk and decided to speak only to her.  She researched my case and found the certificate of certification had never been filed.......result?  $800 of labs paid that week.
Avatar universal
you're right. i know that. but i'm floundering here..i could fix this problem if it involved one of my kids, or one of my patients. don't know why i am having this problem with myself. if i switch dr now, i'll have to start all over? i think my hangup is the date. i have had july 3rd in my head for months, psyched myself up. to be honest, i think i fixated on the date so i didn't fixate on the hep c.

rearfang, i looked up your doc, he's in my plan.  got a phone #?
Avatar universal
I switched doctors 4 wks into treatment, It was too stressful to continue tx in the other environment. You can start while looking for better providers.
Avatar universal
nyhepc: I completely understand the floudering part! I've been there when I was trying to decide WHAT to do about my HepC and then when I decided NOTHING was going to slow down that date I had set im my mind. (of course I eventually did miss that emotional start date by 3 full months as everything seemed to take longer than everyone told me it would!) If someone suggested to me that I change doctors just before treatment I would have been in a major panic not to mention telling them to mind their own business!  I certainly don't mean to create more stress for you....only looking out for your future treatment as your doctor seems to exhibit traits we all are leery about after hearing each other's stories here on this site. I doubt if going to another doctor would start this process over as the leg work has already been done by your present doctor.  There will be no need for new labs, viral tests or new biopsy etc.....What is a concern is your doctor's lack of being agressive to help you in any way possible to help you beat this battle. Everyone here, as I've learned, supports not stopping treatment if you have not acheieved "undetectable" status at week 12...what everyone does agree upon is continuing the treatment if you get at least a 2 log drop and having access to Procrit and Neupogen as needed. Procrit is keeping me on treatment: otherwise I would have had to stop at week 5...I'm now at week 20/48.  How about this idea...Start your treatment on time (once you get the ins. problem solved) but at the same time make an appointment asap with a new doctor and "interview" them stating you are concerned about your present one.....bring your labs and get your copies of your file from your present doctor's secretary...this is your right as a patient.  If you like what you hear from the new doctor you can move yourself to that practice but not compromise your "start date"...Describe your situation when you make the appointment with the new doctor's office so they get you in very soon. I know it is extra anxiety and work on your part but you will at least get to hear the view of another doctor with regard to your concerns. Maybe it is worth another visit with your present doctor explaining what you have learned and ask another time if he would reconsider being as aggressive as you need...I've done that with mine on one occassion when I actually printed out things on this sight to help him understand he must be more aggressive which luckily in my case worked.
Starting treatment when you have made that psychological commitment is so important emotionally. I'm not suggesting you put that date off...just cover your bases and "interview" another doctor. I'll be keeping my fingers crossed for you about your insurance as well.
Best to you, Scott
If rearfang doesn't post I'm sure you could find Dr. Polito's # by calling Albany's information or a yellow pages seach on the internet.
Avatar universal

Squeaky wheel gets greased indeed. I agree. These health companies are all horrible.
Avatar universal
Sorry to hear your having problems with insurance, it doesn't seem right that along with having to deal with the hep c you have to deal with the insurance companies.

It took three weeks for me to get approved for 12 weeks, but I did make a lot of phone calls and actually got one of the billing people from the pharmacy (a hospital pharmacy) to make some calls for me. After 12 weeks they want to see if I get the 2 log drop before they will approve the remaining 36 weeks. I am concerned that after 12 weeks it will take more time for that approval and possibly causing a missed dose.

My brother who is a doctor and thus familiar with insurance company methods recommended that I document each call. Recording the name of who I was talking to, the date and time of each call, and the substance of the conversation. He said don't get mad because your not talking to the policy makers, just be a squeaky wheel as other have said.

My Gastro recommended one of three pharmacies in the area because they had experience jumping through the hoops the insurance companies put in front of them concerning these meds.
Avatar universal
thx cuteous..it's helpful to know someone else has gone thru these problems and come out the other side smiling.

dutch_boy...you aren't creating stress for me, i seem to be creating my own, lol. sometimes one needs a kick in the ...pants... to get moving. i'll call today
Avatar universal
Hi Lorrie,
I've been wondering how you are. The phone # for my doc (Polito--though there are about 8 docs at the practice,) is 438-4483. My first appt. took 6 weeks to get. Maybe the fact that you've already been dx, tested, etc... could speed things up. When you call, explain and try to get a cancellation or something so you don't have to wait so long. They will be able to use the lab work, etc... that you've already had done so you don't have to start all over again. As everyone has stated, be the squeaky wheel. Don't take no for an answer. Let me know what happens.
Lauren
P.S. Did you get hit by any of the flooding up your way? I'm wondering if I'll be able to get up to my camp this weekend.
Avatar universal
How can one have riba rage before one's started tx?  you can't have the sx's of the drug before you take the drug!  come on people!

and some of us did not ever have 'riba rage'--I never understood that phrase b/c I 'raged' before tx,not during and not since.  I always thought the loss of 'emoional control' was more an indicator of the disease-not the meds.


Lovingwife:  Some insureers and doctors prefer peg-intron/riba by Schering Plough, not Pegasys.  you should ask what drugs they approve.  Both work equally well.
Avatar universal
I could be angry before tx.  During tx these drugs do make some of us lose our temper and become quite nasty at the drop of a hat.  I still cannot believe how ugly I could be at times during tx, but it surely got my labs paid.
Avatar universal
no flooding where i am but further north. the northway is closed from 23 to 25, i think, and route 9 is a mess with the additional traffic. plan extra time
Avatar universal
Scott,,Thanks so much! That means alot to me.  I'm doing really good these days and have my 6 month post labs ready to go for first of July. I can't believe you are already at week 20,,,seems like you just got started!  Yes,,,the procrit makes you feel almost human again.  I remember when at my 6 month mark,,,I got so anemic and was winded on anything I did.  Once,,,the procrit took effect,,,it makes a lot of difference in how you feel.  Great to hear you are doing good or at least as good as you can be on tx! ha  It won't be long before we will be doing the count down for you!  Take Care!
Avatar universal
nyhepc, I'm so happy you decided to take the plunge and make that phone call today.  Nothing will be lost...only potentially gained: including your peace of mind. I wish you luck and I hope you get to see the new doctor sooner than later but I wouldn't postpone your "start date". Glad rearfang agreed you won't be starting from scratch....I didn't expect to be the one to give you the nudge you needed to make that call....I'm quite shy and not too overly opinionated usually.
Wishing you the best, Scott

rearfang, So glad that you were able to help nyhepc with the phone number for Dr. Polito in Albany.  How is your treatment going?  It is so nice to read from other "upstaters" in this forum.  I grew up in Johnstown but presently live in Georgia.  Miss those gorgeous seasons and the Adirondacks! Hope you are well and treatment is going smoothly for you.
Scott
Avatar universal
Wow,,,Sorry to read so many are having insurance problems.  That is one thing,,,that I didn't have to deal with so I'm sure that is much frustration added on top!  

Scott,,,you have offered some great advice here and hope things are going well for you at this point.

New,,,,You are so fortunate that you never experienced riba rage,,,,Before starting tx,,,I was always a laid back person and don't anger easily but on tx,,,,That was awhole new story.  There was days,,,I would explode at the smallest things and could feel or what it felt like,,,,blood pressure going sky high.  I would have to after going off on a tangent and seeing "freaked out" written all over peoples faces.  Tell myself to calm down,,,it was the meds lol   Now its funny but I remember what it was like to get so angry.
Avatar universal
honey, thanks for asking...doing fine these days 20/48 and getting close to 1/2 point.  Procrit has been a miracle for me as I feel more like ME again although my counts are still in dangerous low zones...at least I don't worry about passing out after a sneeze anymore!  Fighting the normal sides that most have but all in all amazed how well I'm doing. Wish I had more energy but that is par for the course. Nice to see you post..I haven't seen your name in a while.  When I first posted in Jan'05 I enjoyed your input...very thoughtful, helpful, knowledgable and caring.  Hope you are doing well these days. What you wrote to tonyz above and filling us "newbies" in on his history was beautiful. It is nice to get the full picture of those many brave people who have fought their battles so fully and get that great SVR news at the end. Thank you for all you do to make this sight so meaningful to so many.
Scott
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