Avastin been denied by insurance (Recap of Lost Posts, Topic Created by LadyMox on Dec 03, 2018)
There was a lot of good information shared under this topic during December, 2018 and January, 2019 that I hadn't remembered seeing in previous posts about Avastin. So I'm posting this recap for future reference.
LadyMox
Dec 03, 2018 - 12:19 pm
During all this I'm going though, now my insurance is denying paying for the Avastin. I have no idea how much it would cost out of pocket.
cmb
Dec 03, 2018 - 1:04 pm
I checked the Medical Policy for Bevacizumab (Avastin) at my insurance company's website and found the following:
|
Uterine Neoplasms-Endometrial Carcinoma |
Endometrioid adenocarcinoma; Serous or clear cell carcinoma; Undifferentiated/dedifferentiated carcinoma; Carcinosarcoma |
Single-agent therapy for disease that has progressed on prior cytotoxic chemotherapy. |
So it may be that your insurance company denied authorization because your doctor prescribed it in conjunction with another drug, if their medical policy is similar to this one.
You should be able to find the Medical Policies on your insurance company's website to read for yourself what their policy is. They are usually listed under the Providers section. And sometimes the insurer will approve a drug use despite what their policy says when a doctor or patient asks.
I'm sorry I can't help you with cost information.
LisaPizza
Dec 03, 2018 - 1:33 pm
Also, never underestimate that they will just deny almost as a matter of course unless they're disputed. People are denied all the time and get it overturned after some dispute. It's like negotiating a car price ... they start off with denial and then see if the doctor really means it or not. Also, it can be something as simple as a typo in the diagnosis. Whoever sent the pre auth may have only indicated endometrial cancer without specifying that you already progressed on chemo. You really really really have to be on your doctor's office to find out exactly what was submitted, exactly what your insurance requires and exactly why it was denied, and getting your doctor to fight. You shouldn't have to ... but you really really really do.
zsazsa1
Dec 03, 2018 - 2:23 pm
Get help from your physician's office, and appeal. Also, some states have an insurance ombudsman office, where they will help you if an insurance is denying a needed treatment. Insurance will claim that it is not approved for your cancer, but many cancer drugs are used in many cancers that they have not yet been officially approved for.
I still don't know if you have yet had Foundation One testing done on your tumor. They give you a report of the clinically relevant mutations in your tumor. This can be used as ammo to convince the insurer to pay for certain medications that have been shown to have efficacy in tumors with certain mutations that the medication can target.
I was told by the local oncology center that it wasn't worth testing for Her2/neu status of my tumor, and that the insurer wouldn't pay for the Herceptin. But at another center, with a uterine gyn researcher, he said that he had found a higher rate of Her2/neu, and that if it was positive, the insurer would have to pay for it. He was right, and I'm receiving that too. So if there is an oncologist who treats a lot of metastatic uterine cancer, his office may know how to word the appeal so that it would be covered.
This is where a spouse, friend, or relative can help you. It is so hard to fight the insurer when all your physical and psychological energy is taken up in fighting the disease.
NoTimeForCancer
Dec 03, 2018 - 2:56 pm
Agree - APPEAL.
LadyMox
Dec 03, 2018 - 3:09 pm
My husband has started fighting this, so I wouldn't exhaust myself further. If needed my father in law will be helping with the cost for now so my treatment won't be delayed. Not sure we could afford it indefinitely but within a few months treatment I should know if the Doxil/Avastin is helping. I pray with all might might the tumor gets enough for surgery so I stand some sort of chance at remission.
LadyMox
Dec 03, 2018 - 3:13 pm
Oh I am getting something like Foundation One testing, but it's from Omniseq, some affiliate of Roswell Park. Though it's still genomic testing. I was told those results would take about a month.
janaes
Dec 03, 2018 - 4:33 pm
Im glad your family is helping.
Northwoodsgirl
Dec 03, 2018 - 5:28 pm
Please know there are specific timelines in which the appeal needs to be filed with the insurance company. Also you can ask for an expedited decision. Also there is opportunity for a second level appeal after your first appeal. In some cases you can also have an administrative judge hearing too.
The insurance company denial letter is a standardized letter sent out on behalf of the health plan’s medical director who is a physician who reviewed your pre-authorization request.
If another health plan pays for it find their medical coverage policy online and check out their literature search citation. If they cover it there must have been a few research studies that supported the use of the drug for your specific type of uterine cancer. If they don’t cover the drug then the medical coverage policy bibliography will have studies showing why the drug won’t work.
Not sure if you know that you can have your doctor do the appeal on your behalf.
Some other health plans to check bibliography on Medical Coverage Policy section of their website includes United Healthcare, Cigna, Aetna, Humana, Blue Cross Blue Shield, Medicare CMS National Coverage Determinations. The pharmaceutical company that makes the drug ( product manager or clinical services department ) have lots of study information to prove the safety and efficacy (outcomes) of the drug.
Lori
zsazsa1
Dec 03, 2018 - 7:52 pm
Yes, you can also get help from the manufacturer in appeal
And if your insurance still refuses to cover it, they might give you a break on the cost of the medication.
LadyMox
Dec 10, 2018 - 3:55 pm
We are still flighting this as of right now can't get Avastin. Insurance says that even if we pay for the drug out of pocket (with the companies help) then they won't pay for the Doxil. Ugh. We are still arguing with the insurance but it's not going well.
CheeseQueen57
Dec 10, 2018 - 4:35 pm
Go right to your state department of insurance
https://myportal.dfs.ny.gov/web/guest-applications/consumer-complaint?hn=1&forward=new
Immediately file a complaint with the NY dept of insurance. You’ll be surprised how fast they’ll scramble. I think you do it here.
NoTimeForCancer
Dec 10, 2018 - 4:27 pm
LadyMox, I hope one of the ladies can chime in with some tips or ideas. Proud of you to fight on this! Man I wish insurance companies had to look us in the eye!
Universe
Dec 10, 2018 - 6:52 pm
Hi LadyMox,
1) Avastin Price: $55 per dose. I found this information on google.
2) Doxil Price: This Doxil price guide is based on using the Drugs.com discount card which is accepted at most U.S. pharmacies. The cost for Doxil intravenous dispersion (2 mg/mL) is around $1,234 for a supply of 10 milliliters, depending on the pharmacy you visit. Prices are for cash paying customers only and are not valid with insurance plans.
Maybe you could buy it out of pocket till you figure out the insurance issue and then claim later. Just a thought.
Universe.
LadyMox
Dec 11, 2018 - 11:08 am
We were going to find a way to pay for Avastin on our own but then the insurance says it won't pay for the Doxil for some reason. We have filled several methods of complains but it's taking time. Now my hospital is rounding up paperwork to submit to the insurance that it requested. I'm supposed to get Avastin this Thursday but seems like it won't happen (yet).
Tamlen
Dec 11, 2018 - 2:17 pm
Your insurance's medical director
LadyMox, I'm sorry this has to be such a fight for you, right at a time you've got fight enough on your hands.
Are you able to confirm with your insurance that the insurance company's medical director reviewed your case and rendered the decision? I believe they have to tell you this if you ask. There was a piece in the news a few weeks ago about some insurance companies allowing P.A.s to make approval/denial decisions, even when they shouldn't have been, including serious cases. Several huge insurance companies were found to do this (sorry, I can't recall which ones but have a vague recollection BC/BS may have been one of them) and it's probably a good idea to confirm who made the decision in your case.
janaes
Dec 11, 2018 - 7:46 pm
Boy what a pain in the but. Im sorry you have to fight this money stuff. You have enough to worry about. Boy dont they know how ergent and important this is.
At the same time this just shows what a great fighter you are. I really hope you get this cleared so you can get the treatments you need. I will be praying and thinking of you as you go forward..
Universe
Dec 15, 2018 - 4:45 pm
Thinking of you LadyMox. Were you able to get started with doxil avastin?
Acookie
Dec 20, 2018 - 9:04 am
Hi ladymox, hope you are ok. How did you go with your insurance and the doxil/avastin. Just thought i would let you know that our oncologist was saying avastin slows wound healing down so he generally stops a certain timeframe before surgery. My mum isn't on avastin though. She is on carbo, taxol and herceptin. He just mentioned it when I asked about avastin.
LadyMox
Dec 20, 2018 - 11:49 am
Got started with doxil, still fighting for Avastin
LadyMox
Dec 21, 2018 - 9:52 pm
Avastin been denied for a 3rd time, going for an external appeal. Either way if this round of treatment (be it doxil or doxil-avastian) fails I want to see if I can try Immunotherapy... That is If I can qualify both medically and via insurance.
KatnHat
Dec 22, 2018 - 1:00 am
Insurance companies don't help!
When we're sick and anxious, why don't the companies help us out a bit? That is crazy they're denying but not letting you pay out of pocket without the threat of not paying for the Doxil! Insane and cruel. Your doctor knows you better than insurance wonks. My doctor got involved with me and got a verbal okay the second appeal but they can't make an appt. until it's written! So I'm hoping and hoping I'll get in before the end of the year.
The added stress can't be helping us!
Universe
The Doxil or Doxil-Avastin should make things work for you is my prayer.
MMMT SURVIVOR
Lady Mox, I agree with all the responses so far
I hope that you are able to obtain the relief you need. I can't imagine the stress that this whole insurance ordeal has put on you and your family. Keeping fingers crossed that it gets resolved quickly in your favor. As an fyi, I'm on Avastin only for maintenance after 3 treatments of carbo/taxol over the past 8 years. the hospital bills Medicare $23k per infusion. I asked my onc what the cash price would be if Medicare decided to kick me off. He said it would be $100k for 10 treatments. This is in the ballpark of several responses I've received from other survivors on this board. Sending positive vibes and prayers your way.
Mary Ann
Universe
For the costing information. Very helpful.
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evolo58
Dec 26, 2018 - 7:46 pm
Doxil/Avastin is a very common protocol; especially for progressions/recurrences. About the only reason I can think of is that this is still your first-line treatment, but that is a really weak argument, since you obviously aren't responding to carbo/taxol.
Zsazsa1 has an excellent point ... you could try to go to the manufacturer and see if you can get assistance that way:
https://www.avastin.com/patient/financial-resources.html
Universe
Dec 26, 2018 - 7:53 pm
I came across this article on prices of cancer drugs in various countries. You may take a look, countries like India could be manufacturing at a much lower cost is what I see from the article.
I dont know if it is possible to buy from India and use here- you may ask your doctor.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5641070/
KatnHat
Jan 01, 2019 - 6:31 pm
It said that Avastin has not been studied to be given in this combination (Avastin with Doxcil). It's only supported by Avastin given by itself or with carboplatin and paclitaxel. I'm carboplatin resistant so this wouldn't work! And I need the dodoxcil to attack the cancer cells themselves. The Avastin works on the blood supply.
I found out on the day of my infusion that the insurance had denied it twice. My dear sister ended up paying for the dose so I wouldn't have to wait (approx. $7,000!). The center already has a request in to an organization that will help with costs of drug, but not the cost of nursing care and use of center. My doctor is pretty ticked off about it. He already tried to appeal and now it's in my hands to file a grievance. Maybe this distraction is good for us cancer patients; keeps us in fighting form!
BluebirdOne
Jan 01, 2019 - 7:37 pm
I am so sorry for your plight and thankfully you have a sister with deep pockets. Keep fighting! We are here for you!
ConnieSW
Jan 01, 2019 - 8:02 pm
show 'em who they are messing with.
evolo58
Jan 24, 2019 - 5:49 pm
Must be a new thing with the insurance bean-counters
After getting three Avastin treatments, my insurance company rejected the Avastin.
There was plenty of time to get this sorted. I gave the gyno-onco the OK to do the Doxil and Avastin on November 15th, and my first infusion was December 14th. And the insurance company decides I don't need the Avastin NOW?
They claim I should be on carbo/taxol. Well, if they actually LOOKED at my clinical history, they would see I had my progression four months after the last CT scan, which techincally makes me plat-resistant. Am I really? I have no idea. When I was on C/T, it seemed to work. As you ladies know, I sincerely believe that what happened to me was a trash can fire. The July CT scan, which was actually done properly, mentioned concerns about cancer in the lower right quadrant. My old gyno-onco decided to do a wait and watch. Guess where the cigarette landed?
I am sweating a mean streak as to what my center's billing is going to do about the Avastin I've already received. Looking at the original price, even with a reduction, there is NO WAY I could afford Avastin on my own unless they REALLY drop that price to $55!
BluebirdOne
Jan 22, 2019 - 6:00 pm
Evolo58,
I am so sorry to hear about this. I had heard that as of 2019 that some reimbursements for drugs were going to be changed, but this is terrible. What do they expect you to do? Do they even bother to use the protocols? So angry that women have to fight their insurance for these drugs.
Denise
evolo58
Jan 24, 2019 - 6:06 pm
According to my doctor's office
They will not ... will not ... will not ... bill me for thousands of dollars for the Avastin. Not in the past, and not now. They told me to come in for the infusion tomorrow. I asked the financial counselor four times, and she responded the same way four times. They have made it quite clear that they are going to do the appeal, and my participation is not needed at the moment. I get the impression this is not the financial counsleror's first, fifth or even tenth rodeo recently.
According to them, these infusions WERE pre-approved. They didn't even get any notice that these were denied!
I do NOT feel comfortable trusting strangers and hoping they won't do a 360 if push comes to shove, even if they seem like nice people. Honestly, I'd much prefer a written agreement over a verbal one.
My husband spoke with someone involved with the insurance plan at the company, and apparently, it's pulling this stunt with other people on many treatments and meds; men and women. There is much unhappiness and fear. This is just not right for all of us.
BluebirdOne
Jan 25, 2019 - 1:27 am
I do not blame you for not trusting the insurance company, because they do deny coverage all the time. I am so sorry you have to go through this! Not fair.
KatnHat
Jan 25, 2019 - 12:08 am
We're getting help from a organization
Insurance is still denying; is at what they call Tier 2-peer to peer. My doctor already talked to someone, but they're saying he still needs to talk. Meanwhile, an organization is helping with the cost, but it's very secretive; I can't even get the name! No paperwork other than a forrm I signed and sent with my 2017 tax return. Meanwhile, the Avastin seems to be helping. I had tumors popping out of my muscle in my shoulder, upper arms, upper posterior shoulder and my back. Two were extremely painful. Now, after two doses of Doxcil and 3 doses of Avastin, the tumors have shrunk at least by half and better, NO PAIN! So the combination of attacking both the cancer cells and the blood supply is so obviously working! I need to get a letter out since I don't really trust my insurance to do the right thing (they sent me two letters saying the next step is my filing a grievance but when I talked to someone by phone, they said they were still waiting to hear from the doctor). My next battle is coverage of Neulasta.
Lady Mox, how has it been going with you?
BluebirdOne
Jan 25, 2019 - 1:30 am
I am glad that you were able to get coverage no matter the source. Glad that the Avastin is helping to shrink the tumors. I am so sorry that you and all of the ladies, have to go through this.
LisaPizza
Jan 25, 2019 - 1:11 pm
LastMox, I think of you often and also hope to hear from you 
evolo58
Jan 27, 2019 - 4:16 pm
For now. Actually I see the insurance company's point this time (and this time only). My levels were not that far below the level the first time, and this time, they actually went up even without the Neulasta and are barely below normal. So for now, I'm picking my batttles.
The Avastin is still worrying me, though. My CA-125 after the first Doxil went down over 100 points, even though it often goes UP temporarily after the first Doxil. I am hoping the combo works for me as well. The last thing I'd want right now is to mess with the treatment plan.
Sounds like your doctor is like mine ... doesn't sound like his first rodeo with insurance companies, either. The cost might not be quite what you'd get with insurance, perhaps, but at least it's not 7-freakin-thousand dollars! So, so glad to hear your treamtents are promising. May you continue to get great results!
Lulu7582
Jan 25, 2019 - 3:15 pm
Sending you cyber hugs!! Hoping the insurance has finally covered the Avastin! xoxo
TeddyandBears_Mom
Jan 26, 2019 - 2:00 pm
KatnHat - That is very good news! So glad you are responding to the treatments. I pray that you will continue to improve and dance with NED in the near future.
Love and Hugs,
Cindi
MAbound
Jan 27, 2019 - 8:37 pm
All I can say is I'm worried too and wish I knew her real name. All I can say is I've finally got the courage to look at the Buffalo News obits and can't find any listing for December or January for anyone who could possibly be her, so there is still hope. If she sees this I hope she feels all the care and concern we are sending her way.
Acookie
Jan 27, 2019 - 11:23 pm
Hi mabound
Her profile says last online today.
Ladymox, hope you are ok.
MAbound
Jan 28, 2019 - 9:37 am
I didn't think to check there. Still worried not knowing how things are going, but it's a relief to know she's still with us.
derMaus
Jan 28, 2019 - 1:59 pm
I thought the same thing. I PM'd her awhile ago and not heard back, but was relieved that she's been online. Hopefully she's reading these messages and knows folks are asking. I LOVE how our community looks out for one another.
zsazsa1
Jan 29, 2019 - 3:30 am
LadyMox, just wanted to add that I too think of you every day. I'm hoping that you've been approved for the Avastin, but if not, here is a link to the manufacturer's financial assistance page.
https://www.avastin.com/patient/financial-resources.html
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