Procrit - bcbstx through specialty pharmacy

[miserableandreadytoquit]

I posted before about my 12 week  test showing my HGB as 9.7 after my dosage of Ribavirin had been lowered to 1000 mg. at 8 weeks (was UND 49 then) and having posted here and taking the forum's advice I called my Dr's office last week and insisted on starting with Procrit to help with the inability to breathe and the fatigue.  It was called in to the pharmacy and instantly rejected so I called my insurance (bcbstx) and was told it was a specialty drug and was given the phone number for Triessent because they could help get the drug approved.  I was told 3 to 5 days before I would know the cost and if approved...and am worrying about the budget.  The only posts I can find on the cost of the drug are dated 2007 and am hoping that things have changed since then regarding the drug approval and its cost.  Does anyone on the forum have any recent dealings with attaining Procrit through a specialty pharmacy - how long before approved and what the cost will be?

[willing]

thanks! The experience sounds like a nightmare - particularly after having taken the time to do a benefits review in advance. I assume both levels of internal insco appeal had to be exhausted before you can go into court under ERISA. How long did  the two appeals take? And have you gotten to the point of talking with a lawyer about what law will govern their decision to deny an rx as "not medically necessary" notwithstanding a Dr's justification for the rx?

I'm looking ahead and wondering what the legal landscape looks like. Policy limitations between "good" and "poor" coverage in terms of deductible/co-pay etc. are clearly spelled out in the policy contract but judgment decisions about what drugs are/are not covered under what conditions seem much murkier. Ultimately, if challenged, the court is going to apply some criteria to decide if the denial is justified but I can't find any clues in the policy about what that criteria might be.

[mountainair]

You have to be really careful with the insurance & the specialty pharmacy!  I got a benefits review in advance for neupogen and it was approved w/ a $40 copay/shot, but when the doc actually put in the prescription, it was denied.  They said they only covered it if your diagnosis was certain kinds of cancer or HIV, not for hep C tx - said it "wasn't medically necessary" because current medical literature didn't show evidence of increased incidence of infection due to low neutrophils while on hep C tx. I went through the appeals process, was denied again and then a second-level appeal - denied again.  Also went thru my employer's "Advocacy Group", to no avail.  Now ERISA is the only avenue open to me.  By then the Doc had dose reduced my PEG twice - down to 100 mcg/kg/wk and my riba to 8 mg/kg/day and my WBC has stabilized (but not my hgb).

I suggect having your doc actually submit the prescription rather than rely on a phone call to the insurance carrier...

I hope you get better coverage than I did!  Good Luck!

[willing]

thanks Trin - appreciate the comments.  I can definitely call them and should get a quick  aswer about the epo but the PI is all still up in the air and I expect anyone I talk to wouldn't have an answer. I was just wondering what the legal recourse was in case of denial. Is this one of those ERISA things were insured have basically surrendered their ability to challenge or is there recourse? On one hand, if they cover PIs at all, the total cost to them is no different - they're still looking at 48w soc + 24/28w PI.

re whether starting early or not make sense, I definitely agree there's risk but that risk seemed smaller than more waiting. 1st shot was yesterday and I'll know in a month or so what effect the ntz and high-dose rbv  had on the vl drop relative to my last ('02) tx. If things go well and tela/boce are approved by early summer there will be enough time to do a full 24/28w course of the PI (I'm hoping for boce), The long lead in means the PI will be shutting down PI-sensitive viral replication in a much smaller number of infected cells than if added at the start of tx. The main problem I can see is whether the remaining June-Nov of soc will be enough time to shut down holdover  PI-resistant infected cells.    That Merck press release you linked in another thread suggests  that 24w after end of PI is (marginally) better than 12w so it looks like there's no way to hurry along the demise of those last infected cells.

[Trinity4]

Call Insco and ask them.  It's a specialty drug just like Inf & Riba so it has to defined somewhere in the policy terms.

Willing, I'm going to be completely honest here.  Your method scares me in that much of your success is hinging on the release of the PI's and even if they did get released would your insurance company cover it at that late stage in the game.

I do wish you the best and I think it's a bold move but logically I'm not grasping it.

Trin

[willing]

anyone know the legal nuts and bolts of insco drug coverage denial? I've looked through the terms of coverage of my policy but haven't found language that makes it clear on what basis they can legitimately deny a prescribed drug and how such a decision would be challenged. This is looming on my horizon  because of possible need for epo (already at 3 unit HgB decline after 2w of 19mg/Kg rbv) and more importantly for adding a PI (boce/tela)  6 months into an ongoing soc tx.

[miserableandreadytoquit]

Thanks for the feedback.  I feel better knowing now that I will eventually have it authorized and also be able to pay for it.  I am so tired..........the car gets farther away every morning!!!  But at least the hallucunations subsided a lot when my ribavirin was lowered so I can drive the car safely when I do get to it!! LOL

[paen53]

I used Procrit for much of my tx too. Routinely, I had to go through a "prior authorization" process ( I'm with Medica), a couple days delay, and then I had them (through Walgreens Spec. also). I always had to make sure I called this Rx in at least a week before I needed them to offset any delay.

[jazzy578]

About three months ago my hgb was 9.1 so my doc set me up with Walgreens Speciality Pharmacy.  I had the 4 pack of shots within one week.  This is where I order my tx drugs.  Could any hold up be with your insurance company? When I was almost out of those 4 shots, they called me and set up a reorder.  I didn't have to do anything.  Unfortunately for me, my hgb dropped to 8.7 with a side effect of vertigo so I had to go off it.  We have Blue Cross and our copay was $60.00.  For me, the Procrit was easy to get, but hard to take the sx.

Take care,  Jaz

[eureka254]

I'm not familiar with bcbs, but when my husband was prescribed Procrit, we ran into a similar situation with aetna.  It was processed through their 'specialty pharmacy' by mail order only, and a prescription alone was not sufficient.  Approval or denial was dependent upon whether a lab result of hgb <10.0 was available within the last 10 days at time of prescription or refill. My husband had a couple of denials when his hgb was 10.0 and 10.1, but approvals usually got processed, shipped and received within a week.  As far as cost, we thankfully had a very reasonable co-pay, but the statement of benefits shows the pharmacy reimbursement from the insurance company was $5150 for 8 vials (one month's supply).  Hope that helps.

[nygirl7]

My pharmacist put it through as epogen rather than procrit and changed it from twice a week and put instead 8x a month and it got approved. She really worked hard to get it done but it helped.