Great news- insurance is covering the Gemzar!

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lisa42
lisa42 Member Posts: 3,625 Member
edited March 2014 in Colorectal Cancer #1
Hi again everyone,

As soon as I finished posting my other thread on having had my 3rd Gemzar treatment, I got a phone call from Health Net. As a reminder, they had denied paying for Gemzar for me because it's "not FDA approved for colorectal cancer". I appealed and they denied my appeal. From there, I waited a couple of weeks while gathering more research, former study data. I typed up a 2 page letter (which I edited numerous times before sending) and sent that along with the data information, and the letters from Dr. Lenz and Dr. Fanta (which I believe Health Net never even bothered to read before)- I sent all this to California's Dept. of Managed Care. Today's call came from my assigned caseworker from Health Net's Dept of Appeals and Grievances- that it has now been approved!
What a game you have to play, but this means to never give up!!

I believe their decision to cover it also sets precedent to cover "off market" drugs for other patients as well- so all of you out there who are faced with insurance denials- never give up!!! If they deny you one and two times- keep at them! This was accomplished without any legal help- just a good letter and evidence of why this was medically neccessary for me.

Now... I wait to see if it's working or not! I pray it is, of course, but even if it's not, I believe Health Net's decision today will set precedent for them to pay for future treatments without quite as much of a fight.

Fight on, everyone!!!
Lisa

Comments

  • Sundanceh
    Sundanceh Member Posts: 4,392 Member
    #2
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    :)
    I want you on my "my team" when you get yourself taken care of!

    Could not have happened to a more deserving person than you - cha ching, I think you just got $1350 richer - let's do lunch, LOL:)

    -Craig
  • Jaylo969
    Jaylo969 Member Posts: 824 Member
    #3
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    Happy for you
    This is great news for you and likely for many others in the future. Glad you were approved and will they pay you back for what you have paid out of pocket?

    -Pat

    Ooops! I just read your other post about the refund. That is great!
  • AnneCan
    AnneCan Member Posts: 3,673 Member
    #4
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    Congratulations!
    Way to go Lisa! I am so happy for you, that should you some serious $$! Good for you for being tenacious + succeeding in changing the system. I bet others will benefit from your leading the way!
  • Kathryn_in_MN
    Kathryn_in_MN Member Posts: 1,252 Member
    #5
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    YEAH!
    Good work again at being your own advocate. I'm so glad you got this covered by insurance! Contgrats!
  • just4Brooks
    just4Brooks Member Posts: 980 Member
    #6
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    Way to go!!
    See, I knew it would work out!! That is great news. Now hurry up and feel better so we can go to lunch.

    Brooks
  • grammadebbie
    grammadebbie Member Posts: 464
    #7
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    Yeah Lisa
    You go girl!!!! You are amazing and I am soooo happy that you have such tenacity. It is such an encouragement for all of us. Praying that this treatment does the trick.

    Blessings and BigHugs,

    Debbie (gramma)
  • msccolon
    msccolon Member Posts: 1,917 Member
    #8
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    Great news!
    Another win for the little fish! What a relief for you! Now, prayers it will work for ya!
    mary
  • dianetavegia
    dianetavegia Member Posts: 1,942 Member
    #9
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    Oh wow!
    Prayers have been answered!

    Now I'm expecting good news from the scans!

    Be sure to have them submit for what you've already paid!
  • Paula G.
    Paula G. Member Posts: 596
    #10
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    Such good news, Lisa. So
    Such good news, Lisa. So happy!!! When will you have your next scan to see what it's doing?
    Keep us informed. Love and best to you, Paula
  • lisa42
    lisa42 Member Posts: 3,625 Member
    #11
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    Actually I just got $4,050 richer- that's how much we've already forked out!! :) I had my oncology office fax over the info to Health Net and proof of what I've already paid. SO glad of this!
    My next scan isn't scheduled yet, but should be about 3-1/2 wks from now, after my next treatment. CEA results tomorrow at my onc appt.

    Fight on!!!
    Lisa
  • Nana b
    Nana b Member Posts: 3,030 Member
    #12
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    lisa42 said:

    Actually I just got $4,050 richer- that's how much we've already forked out!! :) I had my oncology office fax over the info to Health Net and proof of what I've already paid. SO glad of this!
    My next scan isn't scheduled yet, but should be about 3-1/2 wks from now, after my next treatment. CEA results tomorrow at my onc appt.

    Fight on!!!
    Lisa

    Yes!
    Lisa, keep fighting! It will make you stronger and don't give on to the BS! XXXXX
  • Mchapp
    Mchapp Member Posts: 95
    #13
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    Nana b said:

    Yes!
    Lisa, keep fighting! It will make you stronger and don't give on to the BS! XXXXX

    Wahoo!!!
    Great news! Sorry that you had to jump thru hoops - but it certainly paid off...I now know where to come for letters - and do you do college reference letters too??? ( I won't need those for a few years - but boy I have written several this year!)

    Sending good, clean CEA and scans your way!
    Michelle
  • RickMurtagh
    RickMurtagh Member Posts: 587 Member
    #14
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    OUTSTANDING!
    Outstanding!!!!!!!
  • Aud
    Aud Member Posts: 479 Member
    #15
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    Lisa...
    ...so happy for you! good news.
    Aud
  • tootsie1
    tootsie1 Member Posts: 5,044 Member
    #16
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    Way to fight for yourself
    Lisa, that's fabulous! And of course I'll be praying it works for you!!!

    *hugs*
    Gail
  • lisa42
    lisa42 Member Posts: 3,625 Member
    #17
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    just4Brooks said:

    Way to go!!
    See, I knew it would work out!! That is great news. Now hurry up and feel better so we can go to lunch.

    Brooks

    Brooks
    Yeah- you know it! Now we gotta find a restaurant w/ a good bathroom for you! (lol-jk)
  • Brenda3.16
    Brenda3.16 Member Posts: 209
    #18
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    tootsie1 said:

    Way to fight for yourself
    Lisa, that's fabulous! And of course I'll be praying it works for you!!!

    *hugs*
    Gail

    Lisa,
    Great News ! I agree
    Lisa,

    Great News ! I agree with Craig, I also want you on "my team" when you get yourself taken care of. I have learned so much from all of your posts the past year.

    I'm praying that it works for you.

    The picture of you and your family is really nice.

    Brenda
  • HollyID
    HollyID Member Posts: 946 Member
    #19
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    Lisa...
    AWESOME news!! You have guts girl. I love your patience for seeing this through. I'm sure they didn't read your doctors letters, but you, yes YOU, did it! If I ever need to write a letter to an insurance company, can we come to you? You seem to know how to do it really well!!
  • lisa42
    lisa42 Member Posts: 3,625 Member
    #20
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    HollyID said:

    Lisa...
    AWESOME news!! You have guts girl. I love your patience for seeing this through. I'm sure they didn't read your doctors letters, but you, yes YOU, did it! If I ever need to write a letter to an insurance company, can we come to you? You seem to know how to do it really well!!

    I'll give what advice I can!
    I'll give what advice I can! The key I believe was really finding overwhelming evidence that this was definitely medically neccessary and that my other options were truly used up.
    Plus, there's always that saying, the squeaky wheel gets the grease. Never give up!!

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