insurance news after a month

After much effort and waiting, I was given the news from my Health Net insurance rep that they sent a fax to my dr's office a whole week ago denying the drug Gemzar for treatment for me. I was almost expecting a denial at this point, but what even made me more upset was the way they were playing games. The day they supposedly sent this denial fax letter to my onc's office (which my onc's office NEVER received), they also requested a copy of all my records to "take it before the review board". Health Net then acknowledged they received all my info, but said "it doesn't matter- this drug isn't FDA approved for colon cancer, so we can't authorize it." So, why in the world did they request the info and why did they say they were taking it before the review board? After exploding and then trying not to cry on the phone, I then spent the next 40 min. on the phone w/ the Health Net rep going over all my history and current situation, then giving info to file an appeal. I gave lots of info, including the references and documentation from three different oncologists (including Dr. Lenz at USC/Norris) about how two clinical trials on this drug showed up to 50% of the advanced colorectal patients had a good response. What more do they need to see? The issue really isn't even money because oxaliplatin and irinotecan are just as expensive or more, and insurance would approve them. Anyhow, after the rep was done taking down all my info, she said that she was submitting this appeal under an urgent status, and that the maximum turnaround time for an urgent appeal is 48-72 hours. Then she said, "I must tell you, though, that they can look at the request and decide that it isn't considered urgent after all, then it could take much longer- I've seen that happen a few times." Before I hung up, I said to the rep to please make a notation on my appeal that I am not a statistic- I am an otherwise healthy 43 yr old mother of three young children & that if I start to decline in health following their denial, that my blood will be on their hands. Would they deny the med. if it was their mother, husband, or kids who needed it?

The lousy kicker is that the onc's nurse was telling me that if I start on oxi or irinotecan instead (just to get started on something, even if they didn't work that well before), that that could really kill my case with Health Net in trying to get the Gemzar approved. They'd think "oh, she does have something on the approved list she can take, so we're not going to approve this other drug." She said it will get to the point where we hae to do something, though. (I thought I was already to that point!) She did say that I could go ahead on it now if I wanted because it's something they do keep on hand & I could pay cash and try to get reimbursed after the fact. I was told that it will cost me close to $4,000 for each three week cycle.
I finally let the nurse know that I still had some leftover Xeloda pills from a year ago & that I had started taking them on Wednesday. I had enough leftover for 2-1/2 weeks at 2500 mg/day. I thought about doing this earlier, but didn't want it to mess up or interfere with the new treatment. I don't know that the Xeloda will do a whole lot, but at least it's something! The nurse said she'd probably have done the same. My oncologist is "off on vacation" AGAIN this week, so I have no way to talk to him, not that he'd even call me if he was there.

In the meantime in addition to now taking the Xeloda, I am juicing, started two weeks ago to avoid sugar, red meat, and milk, am now drinking alkaline water, and taking resveratrol supplements, tumeric supplements, and I just bought some cimetidine (Tagamet) over the counter at Wal Mart. The OTC version is 200 mg a pill. I read on the online study of it a few yrs ago that the rec. dosage is 800 mg/day. I will double check on that. I believe that's also what Dr. Cantrell had said he would put me on (right about the time I stopped his treatment since it wasn't working).
Don't know if all this is nonsense or if there's something to it, but there just may be something to it, so I'm going to try it! It doesn't sound like it could hurt, and I've heard of a few on this board who had mentioned it to their oncs & got prescriptions for it (even though their onc was skeptical, but said it was harmless to take).

So, sorry I have bad news to report- it's been a frustrating month of waiting and dealing with idiots! Onward and forward... I'm now about to go get dinner for my now 17 yr old son's birthday! (and I will drop this topic and slap a smile on my face- lol!)

Lisa