Probably should never assume insurance will cover all drugs or protocols (Prolia)?

I have great insurance coverage (normally) through Blue Cross (traditional-the better plan not an HMO thing). They have covered many things in the past, including Zytiga which is very costly stuff. Well I asked for Prolia instead of Zometa or other similar choices in dealing with bone mets and issues that have been happening over he last 2 years. Find that the insurance company has challenged the Prolia as above the norm and Zometa should be used as first line. They may approve the Prolia it is under review and challenge, I got a letter from them, but they will not approve for certain a second injection as mentioned in the letter.

Seems very stupid to me and didn't see this coming and my docs office never checked prior to see if it were approved, normally. So, we shouldn't assume if with good or great insurance. I had an issue a few months ago where they didn't approve a radiation to my spine mets which I knew was garbage cause they covered prior ones. Well that turned out to be a billing error related code thing, good I questioned it and made them review all that, otherwise a nice fat bill was asked for and they said I was late on payment, even though I just received the bill (and it was dated back almost 1.5 yrs. prior when the service was done....LOL....unbelievable that this to this long to come to be known by me). Luckily it was covered and no payment needed.

The Prolia had no side effects that I could tell were from using it, so I liked that, I had some worries about Zometa and surely it costs enough too. But any new drug today will be outrageous cause of the cost of running our clinical trials and pressures of marketing (notice Zytiga, Xtandi, and others). Just a little rant on how insurance companies dictate what they might cover.

cspivak said...
The billing code error thing has hit us a few times (with different doctors, so conspiracy theorists please don't go there). You really do have to watch them like a hawk so your reminder is spot on.

Get this: Dave had urinary issues, positive DRE, sent for PSA - PSA lab denied because "not covered for routine screening". Not a big charge but still, one more thing to deal with right then....They did fix it.

Wait, what?

PSA test "not covered for routine screening"?? Is that new? If so, that seems like a significant development in the "don't screen" movement. Things that insurance won't cover tend to happen a lot less, it would seem.

Jerry

I just got coverage with Medicare and am still learning what's covered. Medicare will cover one PSA test per year for screening. When I took a lab order into Quest for PSA, they asked me to sign a statement that if Medicare didn't cover it, I would owe $143. I signed it because I knew it would be covered, but if I had any doubt I wouldn't have, because you can order one from privatemdlabs for $40 that goes through Labcorp.

Post Edited (testing123) : 9/16/2014 9:32:59 AM (GMT-6)

I have a high blood pressure medication that includes a diuretic and is covered under my drug plan. The same medication at the same dosage but without the diuretic is not covered by my drug plan. ???????

Zufus ...

Good to hear from you ... I ran into a similar issue trying to get Prolia. It seems that it's only setup for osteoporosis and Zometa / Fosamax are first line.

HOWEVER, I was able to get it's big sister, Xgeva (bigger, more frequent dose) ... which is specifically for us mCRPCa folks with bone mets. I suspect they'll have a very tough time turning you down for Xgeva.

Ray

Interesting discussion on other things we patients contend with and enjoy reading them all. Sharing information is useful for others and gives the heads up and gets you considering more when in the medical mix of things. Maybe will look into Xgeva (SteelGuy), I hope I don't get a bill for the Prolia, if so will fight it and at minimum deduct what Zometa would have cost for similar coverage which only makes sense as it was covered for that in any event. The Lupron shot price tag mentioned above is highway robbery, disgusting to see cashin on patients as the goal. See how cheap it really is at www.northdrugstore.com (they even have generic Lupron in many choices of coverage, starting at one month and onward). A local hospital near here does walk-in psa tests for anybody for a mear $20 and results mailed to you and your doc. (a thing of beauty).....

Makes sense (billing code error).

Have to call them again tomorrow since they approved bone scan and CT scan but denied injections/dyes associated with each. Sigh.....hopefully more code errors.

I was denied Prolia because they filed it as a prescription. After months of fighting and appeals, turned out that it has to be administered in a medical facility, so has to be filed as a medical procedure. That done, went through in 15 minutes.

You want it as a medical procedure to keep you out of the donut hole.

Like David, I had always been approved for everything in my case by Medicare/UHC AARP. I figured out they were paying about $14,000 per month for Lupron/Xgeva, maybe a little less now for Lupron/Prolia, plus paying for Zytiga and $100,000 for Provenge and have approved upcoming SBRT 2 weeks 5 fractions @ 8 Gy each.

Then this week after I had had a DEXA bone density scan as a basline in May 2013, I asked for a new DEXA to measure against that baseline and was denied. Understandable with how many bone scintigrams, CT scans, MRI's to spine, pelvis withour coil and prostate with coil and even an F18 sodium they have covered in last 18 months since my initial diagnosis.

The only thing I have had to pay for since I have a Medicare supplement Plan F that pays all copays and deductibles, is my C-11 Acetate scan at AZ Molecular Instiutute in Phoenix by Dr Fabio Almeida whom I recommend highly. I knew this up front and the test proved useful in confirming 3 micro lymph nodes deemed suspicous on the F18 test.

I truly don't know how guys too young for Medicare can afford this dread disease.

You may want to look into financial assistance as there are foundations like Patient Access Network that pay for my Provengeee travel expenses from FL to Marina Del Rey CA and would have paid copays had I not already been covered, and also pay for my Zytiga to keep me out of the donut hole.

LupronJim