Insurance Coverage

[Guest guest]

I am a nurse in a doctors office and this is exactly how it is. Insurance

companies will dictate what they will pay for and what they won't. The newer

the drug the harder it is to get the ins. companies to pay for it. The

frustrating part is that many times when the doctors office calls to try and get

a med approved you are dealing with non medical people at the ins. company.

Terri

[ ] insurance coverage

Hi,

My doctor prefers to start me on Orencia, but my insurance company

won't cover it. So, now she is going to put me on Enbrel. Is this

typical procedures for insurance companies to dictate what will be

covered and what won't?

It's frustrating when your physician believes certain meds will

benefit their patients and insurance companies dictate coverage. Is

there a way to get around that?

Just frustrated.

Les

[Guest guest]

It has been my experience that it seems many seem to

limit especially when a drug is either really

expensive, not approved for certain conditions, or has

the possibility of being addictive. I've been able to

have my doctors help me file appeals to get medication

covered but there is one I take that I pay for

completely out of pocket as it is the only thing that

will work and they won't cover it whatsoever.

--- <leslielick777@...> wrote:

> Hi,

>

> My doctor prefers to start me on Orencia, but my

> insurance company

> won't cover it. So, now she is going to put me on

> Enbrel. Is this

> typical procedures for insurance companies to

> dictate what will be

> covered and what won't?

>

> It's frustrating when your physician believes

> certain meds will

> benefit their patients and insurance companies

> dictate coverage. Is

> there a way to get around that?

>

> Just frustrated.

>

> Les

>

>

__________________________________________________

[Guest guest]

Having worked for healthcare insurances in the past, it is very common

for them to pull this/ Many times with medications, and even with some

procedures, they state that it is " experimental " and refuse to cover

it. I had it happen to me with Remicaide. I was involved in the trial

study and when the trial was over, my insurance refused to pay for it.

My doctor told them that since I was involved in the study and I

responded well to it, they eventually approved it, but I had $200 co-

pay.

If anything like this happens, it is up to ypour doctors office to

figure out a way to get it approved. Most of the time, all it takes is

just going through the appeal process. From my experience w/ RA

medication denials for infusions, they want patients who have moderate

to severe RA,failed at least 2 oral medications and gold shots. At

least your doctors office has people who know how to navigate

healthcare insurance policies...I had to tell my rheumatologist how the

process went for me to back on remicaide. Good Luck!!

>

> Hi,

>

> My doctor prefers to start me on Orencia, but my insurance company

> won't cover it. So, now she is going to put me on Enbrel. Is this

> typical procedures for insurance companies to dictate what will be

> covered and what won't?

>

> It's frustrating when your physician believes certain meds will

> benefit their patients and insurance companies dictate coverage. Is

> there a way to get around that?

>

> Just frustrated.

>

> Les

>

[Guest guest]

With my insurance company, I had to fail on two other DMARD's before

they would consider a biologic. Even then, I had to wait a month while

the process was going on. I think they were trying to make it difficult

for my rheumy so that he would get frustrated and give up. Actually, my

rheumy assigned it to his fellow.

Sue

On Wednesday, October 31, 2007, at 09:06 AM, Jim and Terri Hauff wrote:

> I am a nurse in a doctors office and this is exactly how it is.

> Insurance companies will dictate what they will pay for and what they

> won't. The newer the drug the harder it is to get the ins. companies

> to pay for it. The frustrating part is that many times when the

> doctors office calls to try and get a med approved you are dealing

> with non medical people at the ins. company.

[Guest guest]

--- Thanks everyone who replied to my question and obvious

frustration. It appears that I'm not alone is this frustrating fight

with care versus insurance coverage.

I am going to start on Enbrel first, if that doesn't work, I'll go to

Humira,with a MTX chaser. If I fail to respond to either biologics, I

will definitely continue to pursuade my rheumy to appeal for Orencia.j

I appreciate all your input and advice. Thanks again.

Les

[Guest guest]

Although it didn't work for me, my RA doc put me on Rituxan. A lot of people

receive good results, I just happened to get NOTHING. But that's another drug

that the FDA has approved for RA.

Good luck!

ltdavis_jrdavis@...

[ ] Re: insurance coverage

--- Thanks everyone who replied to my question and obvious

frustration. It appears that I'm not alone is this frustrating fight

with care versus insurance coverage.

I am going to start on Enbrel first, if that doesn't work, I'll go to

Humira,with a MTX chaser. If I fail to respond to either biologics, I

will definitely continue to pursuade my rheumy to appeal for Orencia.j

I appreciate all your input and advice. Thanks again.

Les

__________________________________________________

[Guest guest]

Vicki, contact Novartis right away.

From: vickistu@...

Date: Fri, 14 Mar 2008 03:15:13 +0000

Subject: [ ] INSURANCE COVERAGE

Yes, isn't it true--we take our health care coverage for granted

until we get a diagnosis like ours--and then Oh Mercy! It is a BIG

deal. I just started a new job working for a medium-sized medical

center in Seattle, WA, and the insurance I have does not cover

GLEEVEC at all. I mean, nothing. They just say that it " exceeds

your benefit. " And that is it. So, now I have 40 days (the amount

of Gleevec I have remaining in my current supply) to figure out

where my next prescription is coming from. Isn't that the worst

thing you've ever heard?!

So--I'm having my own anxiety/pity/distress party. Anybody have any

thoughts/!?

I appreciate this group so much--I am in remission now, and my

disease is behaving itself, but I keep seeing myself without

Gleevec, and it is a frightening sight! Keeps me awake at night.

Vicki Schepman

Lynnwood, WA

Diagnosed 09/06

Gleevec 600 mg/day

Remission as of January, '08 (Molecular level)

>

> > Thank you so much to all of you that answered my Help posting. I

would

> > name you all but would not like to leave anyone out. You are all

so

> > awesome! I feel so much better and am anticipating what my Onc

comes

> > back and recommends. I have already decided to wait a few weeks

then

> > repeat the PCR test. I thank God my Husband is active duty

miltary and

> > we have Tricare. We have been in the AF over 20 years and there

have

> > been many times I have moaned about the Healthcare affiliated

with the

> > Military (mostly if one of my children had an ear infection and I

> > needed a same day appointment and couldn't get one)but Tricare

have

> > been wonderful since my DX and never questioned any test I have

had to

> > have. My Husband was also allowed to stay home with me for much

of the

> > months after my DX too. I love my home country (England) but I

know I

> > wouldn't have got the kind of care I get here For this I am truly

> > grateful.

> > Regards Donna

> >

> >

> >

>

>

>

>

[Guest guest]

Vicki,

I had Bank of America screw me out of my insurance and now I have to rely on

Medicare. One thing you can do is contact the manufacturer of Gleevec and

they may be able to help you get Gleevec at little or no cost. It depends on

your income but they helped me, and I found them to be very nice people. So

as said contact Novartis.

Terry Dailey

41 years old

Dxed April 04

Gleevec 400mg/day

Remission since 04

On Thu, Mar 13, 2008 at 10:15 PM, vickistu <vickistu@...> wrote:

> Yes, isn't it true--we take our health care coverage for granted

> until we get a diagnosis like ours--and then Oh Mercy! It is a BIG

> deal. I just started a new job working for a medium-sized medical

> center in Seattle, WA, and the insurance I have does not cover

> GLEEVEC at all. I mean, nothing. They just say that it " exceeds

> your benefit. " And that is it. So, now I have 40 days (the amount

> of Gleevec I have remaining in my current supply) to figure out

> where my next prescription is coming from. Isn't that the worst

> thing you've ever heard?!

>

> So--I'm having my own anxiety/pity/distress party. Anybody have any

> thoughts/!?

>

> I appreciate this group so much--I am in remission now, and my

> disease is behaving itself, but I keep seeing myself without

> Gleevec, and it is a frightening sight! Keeps me awake at night.

>

> Vicki Schepman

> Lynnwood, WA

> Diagnosed 09/06

> Gleevec 600 mg/day

> Remission as of January, '08 (Molecular level)

>

>

> >

> > > Thank you so much to all of you that answered my Help posting. I

> would

> > > name you all but would not like to leave anyone out. You are all

> so

> > > awesome! I feel so much better and am anticipating what my Onc

> comes

> > > back and recommends. I have already decided to wait a few weeks

> then

> > > repeat the PCR test. I thank God my Husband is active duty

> miltary and

> > > we have Tricare. We have been in the AF over 20 years and there

> have

> > > been many times I have moaned about the Healthcare affiliated

> with the

> > > Military (mostly if one of my children had an ear infection and I

> > > needed a same day appointment and couldn't get one)but Tricare

> have

> > > been wonderful since my DX and never questioned any test I have

> had to

> > > have. My Husband was also allowed to stay home with me for much

> of the

> > > months after my DX too. I love my home country (England) but I

> know I

> > > wouldn't have got the kind of care I get here For this I am truly

> > > grateful.

> > > Regards Donna

> > >

> > >

> > >

> >

> >

> >

> >

[Guest guest]

Vickie, get back to me when you now what's happening with novartis.

I have an extra bottle of Gleevec so if I have to over night it to you I

will.

Lets just say I got lucky last year when my insurance carrier switched to a

chemo mail order company and made me stop using the local Pharmacy. I got

lucky a few times and they didn't charge my ins carrier either Thank God.

They are not the old ones as I used the oldest ones before the newest.

I always knew there would be a good reason to have extra!

ez

[Guest guest]

Wow, , thanks so much! What a Godsend. I will keep in touch.

Vicki

>

> Vickie, get back to me when you now what's happening with novartis.

>

> I have an extra bottle of Gleevec so if I have to over night it to

you I

> will.

>

> Lets just say I got lucky last year when my insurance carrier

switched to a

> chemo mail order company and made me stop using the local Pharmacy.

I got

> lucky a few times and they didn't charge my ins carrier either

Thank God.

>

> They are not the old ones as I used the oldest ones before the

newest.

>

>

>

> I always knew there would be a good reason to have extra!

>

>

>

>

>

> ez

>

>

>

>

>

>

[Guest guest]

We just started taking our son to the Journey Learning Center 817-416-

9797 and so far we are really happy and our son loves to go there. In

addition we have in home therapy since he was 2 and a half through Dr.

Shahla les and Broome and so far they are

also happy with the progress he his being doing at Journey Learning

Center. (They also provide occupational therapy and speech therapy at

Journey Learning Center)

For insurance we use diagnosis code 299.90 and 315.31 and for the

procedure we use

90808 for Supervision Clinical Counseling

90806 for Therapist Clinical Counseling

The invoices need to include the DR BCBA number.

Hope this helps

[Guest guest]

We just started taking our son to the Journey Learning Center 817-416-

9797 and so far we are really happy and our son loves to go there. In

addition we have in home therapy since he was 2 and a half through Dr.

Shahla les and Broome and so far they are

also happy with the progress he his being doing at Journey Learning

Center. (They also provide occupational therapy and speech therapy at

Journey Learning Center)

For insurance we use diagnosis code 299.90 and 315.31 and for the

procedure we use

90808 for Supervision Clinical Counseling

90806 for Therapist Clinical Counseling

The invoices need to include the DR BCBA number.

Hope this helps

[Guest guest]

What if your child doesn't suffer from immune dysfunction?

CR

Insurance coverage

It is all in the billing codes. If it is billed as immune dysfunction it is

covered by most insurances.

Marcia

[Guest guest]

Dr. G treats what is medically wrong with your child so it will be covered.

And our kids are physically sick, they just need proper treatment. Each

child is treated individually because each has different medical issues.

The problem occurs when the children do not get medical treatment or get the

hocus pocus kind of treatment that is not scientifically based.

Marcia

[Guest guest]

We had 75 percent covered by anthem blue cross blue shield in ct. Good luck. Sent from my Verizon Wireless BlackBerryFrom: "jillmckay@..." Date: Thu, 13 Aug 2009 20:14:08 -0000<Plagiocephaly >Subject: Insurance Coverage We just a denial from UHC on our appeal. One of the things mentioned (not in the official letter) is that most companies don't cover these cranial bands. If you have had a band covered (either full or partial) by insurance, will you email me the name of your provider? I'm going to compile a list and see what it looks like and at least argue the point if I can. Jill Cade's mom (7 mo, DOC Band grad 8/5/09) Austin

[Guest guest]

We have Kaiser insurance in Northern California and our plan covered

the band for 80%.

Molly

On Aug 13, 2009, at 1:14 PM, " jillmckay@... " <jillmckay@...

> wrote:

> We just a denial from UHC on our appeal. One of the things

> mentioned (not in the official letter) is that most companies don't

> cover these cranial bands.

>

> If you have had a band covered (either full or partial) by

> insurance, will you email me the name of your provider? I'm going

> to compile a list and see what it looks like and at least argue the

> point if I can.

>

> Jill

> Cade's mom (7 mo, DOC Band grad 8/5/09)

> Austin

>

>

>

> ------------------------------------

>

> For more plagio info

[Guest guest]

We have Blue Shield of CA for our primary and Anthem Blue Cross of CA for the secondary. They both covered the DOC band 100 percent!!Sent from my iPhoneOn Aug 13, 2009, at 1:14 PM, "jillmckay@..." <jillmckay@...> wrote:

We just a denial from UHC on our appeal. One of the things mentioned (not in the official letter) is that most companies don't cover these cranial bands.

If you have had a band covered (either full or partial) by insurance, will you email me the name of your provider? I'm going to compile a list and see what it looks like and at least argue the point if I can.

Jill

Cade's mom (7 mo, DOC Band grad 8/5/09)

Austin

[Guest guest]

Our insurance Aetna approved, but I have a 1000 dollar

deductible for the year, after that is met they cover at 100%

Good luck!

From:

Plagiocephaly [mailto:Plagiocephaly ] On

Behalf Of jillmckay@...

Sent: Thursday, August 13, 2009 3:14 PM

Plagiocephaly

Subject: Insurance Coverage

We just a denial from UHC on our appeal. One of

the things mentioned (not in the official letter) is that most companies don't

cover these cranial bands.

If you have had a band covered (either full or partial) by insurance, will you

email me the name of your provider? I'm going to compile a list and see what it

looks like and at least argue the point if I can.

Jill

Cade's mom (7 mo, DOC Band grad 8/5/09)

Austin

[Guest guest]

We have Blue Cross Blue Shield of North Carolina Federal Employees Program

(standard plan) and it was covered 90% in network and 75% out of network after a

$300 deductible.

Jake-2.5 (DOCBand Grad 9/08)

Jordan-5

>

> We just a denial from UHC on our appeal. One of the things mentioned (not in

the official letter) is that most companies don't cover these cranial bands.

>

> If you have had a band covered (either full or partial) by insurance, will you

email me the name of your provider? I'm going to compile a list and see what it

looks like and at least argue the point if I can.

>

> Jill

> Cade's mom (7 mo, DOC Band grad 8/5/09)

> Austin

>

[Guest guest]

We have MDIPA, which is managed by United Health Care. They denied coverage for a STARband, but said they'd approve a Hanger band. We ended up paying for the STARband out of pocket so we're not sure whether they really would have. I'm not sure how much MDIPA in influenced by United's policies.

Re: Insurance Coverage

We have Blue Cross Blue Shield of North Carolina Federal Employees Program (standard plan) and it was covered 90% in network and 75% out of network after a $300 deductible.Jake-2.5 (DOCBand Grad 9/08)Jordan-5>> We just a denial from UHC on our appeal. One of the things mentioned (not in the official letter) is that most companies don't cover these cranial bands. > > If you have had a band covered (either full or partial) by insurance, will you email me the name of your provider? I'm going to compile a list and see what it looks like and at least argue the point if I can.> > Jill> Cade's mom (7 mo, DOC Band grad 8/5/09)> Austin>

[Guest guest]

I have Kaiser in VA and both DOC bands were covered in full.

Leila

Maysa, 19 mo, DOC band Grad 5.26.09

www.mymaysa.wordpress.com

From: <nwilkens2275@...>Subject: Re: Insurance CoveragePlagiocephaly Date: Friday, August 14, 2009, 1:47 PM

We have Blue Cross Blue Shield of North Carolina Federal Employees Program (standard plan) and it was covered 90% in network and 75% out of network after a $300 deductible.Jake-2.5 (DOCBand Grad 9/08)Jordan-5>> We just a denial from UHC on our appeal. One of the things mentioned (not in the official letter) is that most companies don't cover these cranial bands. > > If you have had a band covered (either full or partial) by insurance, will you email me the name of your provider? I'm going to compile a list and see what it looks like and at least argue the point if I can.> > Jill> Cade's mom (7 mo, DOC Band grad

8/5/09)> Austin>

[Guest guest]

,

Thanks for directing me there. GREAT resource. Does anyone know when that list

was compiled?

, any news on your UHC appeal?

I'm not sure how to proceed with appeal number 2. Their reason is that it

" isn't a covered benefit " ...they don't explain why it isn't covered. Just that

it isn't.

Jill

> > >

> > > We just a denial from UHC on our appeal. One of the things mentioned (not

in the official letter) is that most companies don't cover these cranial bands.

> > >

> > > If you have had a band covered (either full or partial) by insurance, will

you email me the name of your provider? I'm going to compile a list and see what

it looks like and at least argue the point if I can.

> > >

> > > Jill

> > > Cade's mom (7 mo, DOC Band grad 8/5/09)

> > > Austin

> > >

> >

>

[Guest guest]

Nope, no real update. I am probably writing the 2nd appeal this weekend, or

starting it. Same problem here, it is an excluded item on our insurance. I was

told by the supervisor from rapid resolution that most appeals are denied the

first time around just based on the facts and what is/is not covered. They

don't examine the policy or the needs and think about it too much. She said

they usually spend more time examining the appeal the 2nd time around. So, I

am going to ask them to review a couple key points and ask them to justify how

they don't qualify it as DME when so many other insurance companies do.

For us, it is not covered because it is an orthotic that shapes or reshapes a

body part. Hopefully, all of the AMA recommendations, scientific evidence and

just plain logic will finally get them to see the light, but I'm not counting on

it. I am just looking forward to getting to the next stage and actually talking

to people in a hearing.

As far as I'm concerned I am going to make sure they spend the equivalent amount

of $ answer my questions, calls, paperwork, etc, as I did for the helmet. One

way or another, they are paying.

Honestly, I am also hoping to make some dent and/or influence for the future. I

plan on meeting with my HR department and talking to them about how the policy

was drafted, why that item is in there and show them all the problems it has

caused and see if they can directly talk some sense into them. Maybe at least

next time the policy is renewed it will be addressed. If not, well, at least I

know I tried.

> > > >

> > > > We just a denial from UHC on our appeal. One of the things mentioned

(not in the official letter) is that most companies don't cover these cranial

bands.

> > > >

> > > > If you have had a band covered (either full or partial) by insurance,

will you email me the name of your provider? I'm going to compile a list and see

what it looks like and at least argue the point if I can.

> > > >

> > > > Jill

> > > > Cade's mom (7 mo, DOC Band grad 8/5/09)

> > > > Austin

> > > >

> > >

> >

>

[Guest guest]

I'm new to this group. But I have been taking Xolair for several years now with

great results. I have Blue Cross / Blue Shield of Oklahoma. My copay is $1000.00

per month. I can't afford that so I have been getting copay assistance from

several funding groups. They are not getting funding currently so that means I

have will have to stop taking Xolair.

THE REASON I JOINED THIS GROUP IS TO FIND PEOPLE THAT ARE GETTING COVERED BY

THEIR INSURANCE COMPANY. so i can possibly switch from my current company to one

that covers Xolair. Please list your company and what state you are in so other

people can use the information. This is a great drug with a lot of people that

are benefiting from it but can't afford it. PEACE

[Guest guest]

Blue Cross Blue Shield covers my Xolair. I am  with the Alabama group but I

live in Georgia. I pay $100 for a three month supply. Medco is the medical

company and they get it from another company. All meds that we take on a long

term basis has to be obtained from Medco. I had to pay $100 for the first three

months but after that I went to every three months. I think you should talk with

the specialist at the drug company first. They can help you. My hsuband's best

friend recently had kidney transplant and he is now getting all of his

expensive meds through the company that make them. They contacted them and with

the help of his doctor's office, the meds are now free.

Gwendolyn Rafter

From: tericcrawford <tericcrawford@...>

Subject: [ ] Insurance Coverage

Date: Wednesday, February 17, 2010, 11:51 AM

 

I'm new to this group. But I have been taking Xolair for several years now with

great results. I have Blue Cross / Blue Shield of Oklahoma. My copay is $1000.00

per month. I can't afford that so I have been getting copay assistance from

several funding groups. They are not getting funding currently so that means I

have will have to stop taking Xolair.

THE REASON I JOINED THIS GROUP IS TO FIND PEOPLE THAT ARE GETTING COVERED BY

THEIR INSURANCE COMPANY. so i can possibly switch from my current company to one

that covers Xolair. Please list your company and what state you are in so other

people can use the information. This is a great drug with a lot of people that

are benefiting from it but can't afford it. PEACE