Questions on Avastin & Insurance Coverage Problems

ChristineACC

Hello!

I've been a regular lurker on this board since my mother's diagnosis with Stage IV colon cancer about 15 months ago. It's been a wonderful source of information and hope for me.

My mother is currently on her second round of chemo treatments. First round of 5FU, Oxilaplatin, and Avastin resulted in clean scans for several months, and currently she is on 5FU, Camptosar, and Avastin, which is working well this time too, thankfully.

Unfortunately, her insurance company (a BCBS plan) will not pay for this round of Avastin, stating that Avastin is approved as a first- or second-line treatment, but will not be covered for both. (Her onc says that using Avastin is a standard protocol for her diagnosis.)
A secondary issue is that her insurance company is now also denying coverage for Neulasta shots, claiming that this is unnecessary treatment, although it is what is keeping her WBC count at an acceptable level so she can continue with chemo.

I am wondering if this is this common practice among insurance companies? Has anyone else encountered this type of issue? Does anyone have any experience fighting insurance companies on these types of issues -- if so, can you offer a bit of guidance on how to go about this? (Her doctor's office has already appealed the claims denial with no success.)

Thanks in advance for the help!

Best wishes to all,
Christine

Hatshepsut

Avastin and Insurance Coverage
Christine: I'm so sorry your mother is faced with not only her fight against colon cancer but also a fight for coverage with her insurance carrier.

My husband is a cancer survivor and he and I also had a monumental battle with Blue Cross (now Anthem) of California. If you type my screen name (Hatshepsut) into the search box towards the top of the page, you will find several posts from me about our battle and the replies of kind people on this board who gave us moral support.

In the end, we were able to overturn the company's denial by filing an appeal with the California Public Employees Retirement Board. My husband is a university retiree and his insurance is purchased through PERS. For that reason, our appeal was made through PERS. The way your mother buys her insurance will dictate the way the appeal must be made. Does your state have a state insurance commissioner? That may be the route you will need to follow.

Hope this helps.

Wishing your mother a good recovery and wishing you peace of mind,

Hatshepsut

CherylHutch

Insurance Companies
Hi Christine,

I'm not sure where you are located (Canada or the US), so am not sure if insurance companies work the same, but I did find out here in Canada how it works.

If your insurance company is through work, then the employer has bought an insurance package to cover their employees. The Employee Benefits dept. can customize their insurance policies to what they think works best for the "generic" employee. For instance, up here where I am, the BC Cancer Agency pays for most (if not all) IV chemo drugs that are injected through an IV or a port. So, my insurance policy does not cover chemo drugs since they are paid for by the Cancer Agency. Well, when my oncologist put me on an oral chemo while I was getting radiation, she chose this particular oral chemo because it would be easier on my system to have it orally than injected... but my insurance company wouldn't cover it because it was a Chemo drug and they told me that the Cancer Agency covers chemo drugs. But the Cancer Agency says "No, we only cover IV chemo drugs, so the insurance company is to cover the oral chemo." Meanwhile, I felt like a dishrag that was being tossed about and here I was the PATIENT!

Luckily, a girlfriend who works for a company that puts together company insurance benefits explained how this works and that the Insurance company was turning me down because of the insurance package my employer had purchased and that I had to talk to my employer, explain the problem and they could then authorize the insurance company to pay for the chemo... but approval had to come from the Employer. Now how is a patient suppose to know this???

So, I got in touch with personnel at work, who got in touch with an Employee Benefits manager and within an hour, the oral chemo was approved. Had I known that was what I could have done from the start, I would have saved myself days of frustration!

So, if your insurance company is a benefit that is paid for by an employer, or a "group" benefit, then go to the source... the people who pay for the group insurance and explain the problem. It's quite possible they can approve on an individual case basis.

I have no idea if this works the same way in the US.

Hugggggs,

Cheryl

msccolon

CherylHutch said:

Insurance Companies
Hi Christine,

I'm not sure where you are located (Canada or the US), so am not sure if insurance companies work the same, but I did find out here in Canada how it works.

If your insurance company is through work, then the employer has bought an insurance package to cover their employees. The Employee Benefits dept. can customize their insurance policies to what they think works best for the "generic" employee. For instance, up here where I am, the BC Cancer Agency pays for most (if not all) IV chemo drugs that are injected through an IV or a port. So, my insurance policy does not cover chemo drugs since they are paid for by the Cancer Agency. Well, when my oncologist put me on an oral chemo while I was getting radiation, she chose this particular oral chemo because it would be easier on my system to have it orally than injected... but my insurance company wouldn't cover it because it was a Chemo drug and they told me that the Cancer Agency covers chemo drugs. But the Cancer Agency says "No, we only cover IV chemo drugs, so the insurance company is to cover the oral chemo." Meanwhile, I felt like a dishrag that was being tossed about and here I was the PATIENT!

Luckily, a girlfriend who works for a company that puts together company insurance benefits explained how this works and that the Insurance company was turning me down because of the insurance package my employer had purchased and that I had to talk to my employer, explain the problem and they could then authorize the insurance company to pay for the chemo... but approval had to come from the Employer. Now how is a patient suppose to know this???

So, I got in touch with personnel at work, who got in touch with an Employee Benefits manager and within an hour, the oral chemo was approved. Had I known that was what I could have done from the start, I would have saved myself days of frustration!

So, if your insurance company is a benefit that is paid for by an employer, or a "group" benefit, then go to the source... the people who pay for the group insurance and explain the problem. It's quite possible they can approve on an individual case basis.

I have no idea if this works the same way in the US.

Hugggggs,

Cheryl

If it were so simple!
I'm laughing at your naivete! Here in the US, the insurance companies have all the control. Regardless of the fact that they have no medical experience and have no personal contact with their clientele, they are the ones who say they will or will not cover something. Of course, you always have the right to challenge them when they deny coverage, and sometimes you wind up doing that more times than you would like, depending on your insurance company. I have been covered by TRICARE, so the experience has been relatively painless; however, i still have had to fight them on a few things, one of which took 2 years to resolve! Patient Advocate Foundation is a great place to find someone to fight for you against the insurance companies and they don't cost a thing! They assign you a case worker, who calls you to get the details, then conference calls your insurance company to resolve the issues. They did an awesome job for me and would recommend them to anybody. In the US, if your company policy doesn't cover prescription drugs, it doesn't cover prescription drugs. But if you have prescription drug coverage, which ones wouldn't be covered would be up to the company providing the prescription drug coverage, but i don't believe there is an ability on their part to pick and choose WHICH prescription drugs they will cover; except for experimental drugs, that is.
mary

changing2

WOW!
I'm to try Avastin AGAIN in a few months....better check my insurance first! Thanks!

CherylHutch

msccolon said:

If it were so simple!
I'm laughing at your naivete! Here in the US, the insurance companies have all the control. Regardless of the fact that they have no medical experience and have no personal contact with their clientele, they are the ones who say they will or will not cover something. Of course, you always have the right to challenge them when they deny coverage, and sometimes you wind up doing that more times than you would like, depending on your insurance company. I have been covered by TRICARE, so the experience has been relatively painless; however, i still have had to fight them on a few things, one of which took 2 years to resolve! Patient Advocate Foundation is a great place to find someone to fight for you against the insurance companies and they don't cost a thing! They assign you a case worker, who calls you to get the details, then conference calls your insurance company to resolve the issues. They did an awesome job for me and would recommend them to anybody. In the US, if your company policy doesn't cover prescription drugs, it doesn't cover prescription drugs. But if you have prescription drug coverage, which ones wouldn't be covered would be up to the company providing the prescription drug coverage, but i don't believe there is an ability on their part to pick and choose WHICH prescription drugs they will cover; except for experimental drugs, that is.
mary

Insurance Companies
Hey Mary... I realize that the two countries do do things very differently, but I was thinking that it's possible if your insurance is a benefit of an employer there might be some give and take or negotiation.

I had no idea when the insurance company turned down my Cebacitabine, that I could turn to my employer and say, "Help!". The insurance company was following the book and the plan that the employer provided for their employees covered A, B, and C, but not D. The fact my onc wanted me to have D and felt that the oral chemo would benefit me more than going on the pump for 6 weeks straight, then that was good enough for my Employee Benefits department. All I did was call my Benefits caseworker and said, "I don't know what to do!! I have to start this med when I start my radiation on Monday, but I can't afford the $900 (and that's with our 80% subsidy) to get the meds for Monday". So she called my onc to get the official drug #, then she called Pacific Blue Cross and said that this was approved for me... and Pacific Blue Cross then processed it.

The point being, I had no idea if I was getting any grief for any med that was prescribed for me, then I was to just call the employer benefits worker and let her deal with it.

So yes, I realize not everyone's insurance works this way... and from some of the horror stories I've heard about companies in the States, I seriously don't know how you all do it. I think I'm a wuss ... and wouldn't know how to fight an insurance company if I had to. I'd just get angry and break into tears

Hugggggs,

Cheryl

msccolon

CherylHutch said:

Insurance Companies
Hey Mary... I realize that the two countries do do things very differently, but I was thinking that it's possible if your insurance is a benefit of an employer there might be some give and take or negotiation.

I had no idea when the insurance company turned down my Cebacitabine, that I could turn to my employer and say, "Help!". The insurance company was following the book and the plan that the employer provided for their employees covered A, B, and C, but not D. The fact my onc wanted me to have D and felt that the oral chemo would benefit me more than going on the pump for 6 weeks straight, then that was good enough for my Employee Benefits department. All I did was call my Benefits caseworker and said, "I don't know what to do!! I have to start this med when I start my radiation on Monday, but I can't afford the $900 (and that's with our 80% subsidy) to get the meds for Monday". So she called my onc to get the official drug #, then she called Pacific Blue Cross and said that this was approved for me... and Pacific Blue Cross then processed it.

The point being, I had no idea if I was getting any grief for any med that was prescribed for me, then I was to just call the employer benefits worker and let her deal with it.

So yes, I realize not everyone's insurance works this way... and from some of the horror stories I've heard about companies in the States, I seriously don't know how you all do it. I think I'm a wuss ... and wouldn't know how to fight an insurance company if I had to. I'd just get angry and break into tears

Hugggggs,

Cheryl

tears a plenty
trust me, I did as well! Which, actually helps get a bit of sympathy from the person on the other end of the phone, at least it did for me! I am very envious of how relatively easy it is for you on the insurance end of things! We have heard a lot of promises about fixing what ails our health system during the recent election, so I am hoping SOMETHING comes out of it. I wish I could go to someone besided the insurance company! For that matter, come Jan 29th when my benefits run out (the extended COBRA) I will wish there was somewhere AT ALL I could go to! I am working on what to do when that happens and it's looking like i am going to have to change living situations. However, I am willing to do ANYTHING it takes to continue this fight so ...
mary