Insurance denies medication to my sister!

[Laurie]

My sister, Lisa, has terminal breast cancer. She has been dealing with breast cancer for 7 years and this August we learned she is now Stage IV. She has done chemo, mastectomy, radiation. She is currently receiving chemo 3 times per month, once a week for 3 weeks with one week off. She had full brain radiation a couple of months ago and full brain radiation causes some pretty awful side effects. Her face was constantly swollen, she could not hear, her ears are always plugged and she has no taste. She went to an Ear, Nose and Throat specialist and had tubes put in her ears and that helped some, but still she had swelling and pressure in her sinuses. So she was given Nasacort and now insurance is denying to pay for it because it's a steriod.
Hello my sister is TERMINAL--she is dying from the cancer invading her body. Insurance has no problem paying for the OPIATES she takes daily but they won't pay for a nasal spray that actually works to relieve her symptoms?!
I, of course, am more than upset. I am writing a letter to both the insurance company and drug company. I certainly want the drug company to know insurance is denying to pay for a drug that helps a terminally ill cancer patient. If nothing is resolved by letter writing I will be going to the local television stations here and I'm willing to take this to Wisconsin Legislation if necessary.
If anyone else is interested in writing a letter to help get Lisa the medication that helps her, please PM me so I can give you the information.
Also keep your fingers crossed that they will turn their decision around and soon.

 

[Rebecca]

That is completely ridiculous. I actually said "what?!?!" when I read the title. Any chance the company is Blue Shield?

 

[Laurie]

Yep Blue Cross Blue Shield. And that amazes me because they are an insurance company who grants gastric bypass--and most don't. Again you're going to allow opiates on a daily basis for pain but not a steriod nasal spray? Unbelievable!

 

[3CsMommy]

You may not need to write a ticked off letter to the drug company quite yet.

1. Has the MD called the insurance company to try to get it authorized? If it's nonformulary for her insurance (which it might be; depends on what drug company they're in bed with), the rejection can be overridden if the doctor is willing to call and harangue someone. "Prior Auth Required" isn't the end of the world, but it's a darned annoying bump in the road.

2. If the doctor has called and it was still refused, look into "prescription assistance programs" (the things Montel Williams is always talking about). There may be special ones available to your sister because she's stage 4, though I can't think of any off the top of my head.

3. The manufacturer has a rebate card thing listed on their website: http://www.nasacortaq.com/offers/default.aspx It's not much, but even $20/mo will help a little, and that discount might apply even if you can get the insurance company to pay on it.

4. Shop around. It's a brand name and a specialized delivery system, so it's not going to be on anybody's $4.00 list, but generally, larger chain = larger volume of drugs purchased = larger 'discount' from the manufacturer = somewhat lower price to the customer. Then, ask if her regular pharmacy will price match. Some will, some won't, but considering the extenuating circumstances, there are pharmacists who will do it, or can come up with even more alternatives and options than I've listed. (I'm just a tech; I don't know how this works in all cases. But it really frosts my cupcakes when I hear of someone that's very sick being given the run around. She might not have a lot of time left; I don't think what she has should be spent worrying about paying $100+ for a medication that it costs the manufacturer pennies on the dollar of purchase price to make.)

5. You all have my best wishes and positive thoughts going your way. My mother's mother fought breast cancer for 4 years, went through extremely aggressive treatment and still it took her faster than expected. In all honesty I didn't really like her much, but nobody deserves to wither that way, or watch their loved one fade. :broken:

 

[Rebecca]

My grandad works for them, if you like I can call tomorrow and ask him to fix it and/or ask him what would be the most effective approach for you.

 

[DaphnesandFreddysmom]

We have blue cross/blue shield and they never cover anything. It's always a big fight to get them to pay for our medication.

 

[Laurie]

They have gone through all proper channels, the doctor's office has exhausted their efforts. I recommended having Lisa's oncologist call but my mom says it's not for him to to do. I HAVE to write the letter just because. Because I'm appalled, truly, that medication would be denied a terminally ill patient. My mom is a retired nurse and actually called in several favors and has gotten a lot of samples and promises to keep Lisa in samples, but still it's the fact they are denying it. It's a flipping nasal spray for crying out loud!

 

[Cimredopyh]

I do not know enough to give any advice, but i wanted to say that it is so very very unfair that you are being given the run around in this situation. Sending best wishes and good thoughts for Lisa as always.

 

[eroomlorac]

No, no, no, no, no. That is not right. Let me know if I can help in any way, Laurie.

 

[Lmbswimmer]

Most likely there is an appeal process. I know that is how my dad had to get the 24 hr blood glucose monitor thing for his insulin pump. The state board on insurance (not sure of the exact name) should be able to help. I believe that you will most likely have to write 2-3 letters, get denied every time, and then threaten to sue before they will cover the meds. This is what happened with my dad. They usually will not allow it to get to the actual litigation stage. The main reason being that if they are found guilty in court then that sets the precedent for them to cover it for everyone.

However if they make you jump through hoops and you don't know the hoops a lot of people will back down and they won't have to cover it. I would suggest consulting with a lawyer who is savvy in insurance or talk to an insurance broker. An agent that does not work only with BCBS. Find an agent that works for multiple agencies, they might be willing to spend a few hours talking with you about your options and how to write/who to write those letters to.

Good luck, insurance is a bunch of hoops.

 

[alpayton]

The state board on insurance (not sure of the exact name)......

That'd be your state's insurance commissioner....

You may not need to write a ticked off letter to the drug company quite yet.

1. Has the MD called the insurance company to try to get it authorized? If it's nonformulary for her insurance (which it might be; depends on what drug company they're in bed with), the rejection can be overridden if the doctor is willing to call and harangue someone. "Prior Auth Required" isn't the end of the world, but it's a darned annoying bump in the road.

2. If the doctor has called and it was still refused, look into "prescription assistance programs" (the things Montel Williams is always talking about). There may be special ones available to your sister because she's stage 4, though I can't think of any off the top of my head.

3. The manufacturer has a rebate card thing listed on their website: http://www.nasacortaq.com/offers/default.aspx It's not much, but even $20/mo will help a little, and that discount might apply even if you can get the insurance company to pay on it.

4. Shop around. It's a brand name and a specialized delivery system, so it's not going to be on anybody's $4.00 list, but generally, larger chain = larger volume of drugs purchased = larger 'discount' from the manufacturer = somewhat lower price to the customer. Then, ask if her regular pharmacy will price match. Some will, some won't, but considering the extenuating circumstances, there are pharmacists who will do it, or can come up with even more alternatives and options than I've listed. (I'm just a tech; I don't know how this works in all cases. But it really frosts my cupcakes when I hear of someone that's very sick being given the run around. She might not have a lot of time left; I don't think what she has should be spent worrying about paying $100+ for a medication that it costs the manufacturer pennies on the dollar of purchase price to make.)

5. You all have my best wishes and positive thoughts going your way. My mother's mother fought breast cancer for 4 years, went through extremely aggressive treatment and still it took her faster than expected. In all honesty I didn't really like her much, but nobody deserves to wither that way, or watch their loved one fade. :broken:

Just wanted to say that as a pharmacy technician for 13 years and as the daughter of a pharmacy owner/pharmacist for the past 30+ years - this is getting to be a pain in the side of every single person out there. But yes....she's right in everything she's said above. Formularies are ridiculous - Tiers are ridiculous....the minute insurance companies figure out what everyone takes, they change the formulary and make the meds that everyone takes unavailable for them unless they go thru more hoops to get them. It's simply the most ridiculous thing I've ever seen. My opinion is this....if you have insurance (lucky these days) and you have a doctor that prescribes something for you, then your insurance company should pay whatever part they're supposed to pay per contract - no matter what drug it is...period. Drug companies should not be allowed to court/date the insurance companies in order to get on their formularies. They should all be there to begin with.

 

[Rickman]

Just wanted to add; the insurance board here in Ill. was very helpful when I had a problem with our insurance! Had them pay a [inflated] $5600 bill for my last MRI, as it was part of my treatment, done 6/3 and insurance lapsed 5/31!
If you can talk to the right person there, you should see results!

 

[Chinniechantel]

I would love to write a letter for you Laurie. Maybe on my legal letterhead (haha j/k). Let me know the information, that is just horrible. They have to cover something that is life or death. I am so sorry your family and she are going through this. Prayers being sent as usual, she is always in my prayers.

 

[Jeanette]

Just out of curiosity, how much does something like that run?

Oh, and I have had my insurance company deny me for things like the most widely used anti-depressant (for an anxiety disorder). I gave the phone number for my insurance company to my doctor and he called and argued with them for about 30 mins, trying to get them to tell him what was actually covered and they said that they couldn't disclose that and that I would just have to show up with a prescription and see if they would pay for it!

I'm covered for most things that you could think of. But once in a while, the insurance company likes to be.... well, you know.

 

[Riven]

I know this will probably come off as rude or uncaring, but it's a real honest question.

If she is terminal that means there is nothing they can help right? So why is she subjecting herself to chemo if it makes her so miserable? I'm really not trying to be mean or rude, I just want to know if there are advantages, will it help extend her time here, reduce suffering what?

I know people who have had cancer, a couple friends of our family, my exes brother ( who I'm close to) his wife is on the tail end of dealing with colon cancer, but never terminal cancer so I'm just trying to understand. I know that personally, I'm at peace with death, and I don't want to suffer or have my family watch me suffer.

I hope that you can get them to pay for it, is there some other med that would work that is a different type?

We have BCBS, but I know we have a very exceptional plan. We've never had any problems with them, they even cover my acupuncture. Which was something I was going to ask you, do they cover acupuncture? Has your sister considered it as a pain reliever? In some countries it's widely used during surgeries instead of drugs, especially when it's best if the patient stays awake, such as c-sections, and even brain surgery!

That might be something to look into if she would be willing to give it a try. I love it, it truly pulled me out of my rut and got me going again, I recommend anyone try it.

Good luck, and well wishes to you, your family, and especially your sister.

Forgot to add, some companies offer services that help pay for drugs that aren't covered, have you contacted the pharmaceutical company about the situation? Maybe they would be willing to help out?

 

[nicki]

That is a shame. It's disgusting people have to go through this on top of not being well. I think my insurance has something to do with BCBS. So far they have been good to me. Knock on wood. My mom and both of her sisters have had to have tumors removed from their breasts. All have been fine. My mom does not have health insurance and received financial assistance from the cancer society(i think). I can't imagine what you are going through. I'm sorry your family has this to deal with.

 

[Jeanette]

My friends mom was going through some tough times and was terminally ill. She opted to spend time with her daughters and not go through treatment because she was terminal. But that's not for everyone. I'm not suggesting it or, on the other hand, judging anyone for wanting to go through treatment. I'm just responding to Riven's comments.

Her doctor said that sometimes terminally ill patients feel obligated to go through treatments for the sake of their family. They don't want the family to think that they have given up and want to give them some hope.
Again, I'm not saying that's what's happening here, just telling her story.

*hugz*

 

[Riven]

Interesting, yes, I don't mean to judge or suggest what people should do, I was just wondering why she chose that path I guess?

 

[Moo-Shoo Mom]

Laurie, I'm so sorry to hear about this situation.

I asked my fiance, an insurance claims agent, for any possible advice for this situation. He works with situations just like this every day.

He told me that the best option would be to request a copy of the insurance policy from the insurance company. Look over the benefits section of the policy and find out what it states about coverage. The second place in the policy to check would be the Limitations and Exclusions to see if they specifically state that they will not cover that drug, or a blanket statement about Steroids. In the event that you're unable to find any exclusion, and there is a benefit in the policy for drugs, you should write a nicely worded letter to the insurance company requesting that the charges for the medication be considered for benefits and explain the situation in a calm manner. If its not excluded and is listed in the benefits, then you're in great shape.

He's assuming though that it’s probably either not listed as covered, or specifically excluded. If that's the case, then it's likely not going to be covered. Reason being is that insurance companies are highly regulated and will pay things EXACTLY as they fit into the policy. This is to protect the company from lawsuits specifically regarding discrimination. For instance, if they pay it for your sister, they suddenly have to pay it out for everyone else. So it opens a huge liability to the company, and they’re unlikely to make an exception despite the circumstances.

Just remember that the people that you're speaking with at Blue Cross Blue Shield don't want to deny the claim. They don't like upsetting people on the phone, and they would love to help you. They just need a legal reason, or a request in writing to consider the benefits for the medicine. Remember to word things nicely on a letter or to speak calmly to those on the phone with you, as people aren't inclined to help people who are threatening to go to the insurance commission or news groups (from solely an insurance company stand point -- it may be different for Blue Cross Blue Shield though, as they're a major medical company as opposed to only insurance). Basically, if the company excludes it, they have every right to deny the medication.

But his first and foremost advice is definitely that if you haven't yet, request a copy of the insurance policy from Blue Cross Blue Shield, read it thoroughly for the items discussed above, and take action accordingly, such as to write a letter to them explaining where you believes this drug fits into the benefits section of the policy. He also advises (quite frankly) that it would be a waste of your time and money that could be spent on medicine to get a lawyer if (s)he's just going to tell you that the insurance contract doesn't cover it anyway.

I certainly hope you can find something that you can work with within the contract. Insurance really is, like others have said, a bunch of hoops, and I wish the system really worked better. Good luck with everything, and I truly hope that everything works out well for you and Lisa.

 

[Midwest Exotics]

I agree, totally ridiculous. So do they expect someone who is extremely ill to go out & get a job so they can afford to have insurance or at least foot the out of control med bill?

That breaks my heart!!!!

My heart goes out to you, your sister, & the rest of your family! There isnt anything i can say to make it better, but ive been praying for her since your first post!

Keep up the fight, your sister deserves that!

Good luck!!!!!!