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MaineRottweilers 07-27-2017 12:30 PM

Insurance Frustrations
 
Hey everyone,

I'm dealing with a bit of a blow today. I opened a letter from Aetna that denies coverage for both Herceptin and Perjeta. I spent two hours on the phone with multiple departments and got no where with them.

After covering them for nearly two years, these drug are no longer covered by my plan. I am starting an appeal but my next treatment in on August 8th. Seriously? My plan can just change midstream like that? My premium didn't change.

Has anyone else had something like this happen? We all know how important H&P are to us. I checked and Kadcyla is not covered either. So how is a MBC with HER2+++ disease to live if insurance doesn't cover these pharmaceuticals? I'm feeling totally frustrated and just a little bit defeated. I have to muster up some energy to fight Aetna but I really don't know where to start.

lkc Gumby 07-27-2017 01:37 PM

Re: Insurance Frustrations
 
Hi Tracy, sorry you have to deal with this. Honestly having to fight with insuranc companies over denied needed care makes my blood boil. All insurance companiies have medical directors for different medical conditions. Ask .. no demand to talk to the oncology head for your area and plead your case.
As a subscriber you have the right to appeal directly to that person.
good luck!

jacqueline1102 07-27-2017 01:39 PM

Re: Insurance Frustrations
 
Hi Tracy,

Call your cancer center immediately. Your oncology team (doc and social worker) will get on the phone to the Aetna drones. I have known many an oncologist who will fight for their patients.

Goodluck

Kathy T 07-27-2017 02:17 PM

Re: Insurance Frustrations
 
Hi Tracy, I have Aetna and they have been covering Herceptin and Perjeta for me the past 4 years. I hope this is not a new policy.
Kathy T

Kkmom 07-27-2017 07:28 PM

Re: Insurance Frustrations
 
Tracy,
I am sorry you are having to deal with this stupid game the insurance companies like to play. I work in a doctor's office. This is what you do - Contact your doctor's office and find out if they have received the same documentation you have for the coverage denial. If so, in the documentation, the may direct your doctor to do a prior authorization for the prejeta and herceptin. Otherwise, they may ask for a peer to peer consult - between your doctor and a doctor on staff at Aetna (which when you think about it, is a total insult). Then the next step is the total appeal process. Whatever you have to do, keep pushing them - in my experience the wheel that squeaks the loudest gets the grease. Don't stop till you get what is rightfully your right to health coverage. Sorry if I sound too militant.
Pam P. S. - If I remember correctly there is plenty of assistance to reduce the cost for herceptin and perjeta - and it doesn't matter what your household income is - At your doctor's office, they may have a social worker on staff and I found they could be very helpful and informative.

donocco 07-27-2017 10:31 PM

Re: Insurance Frustrations
 
The suggestions Ive read all are excellent. Let me add one more aggressive. It is beyond moraity and sickness thathealthinsurance companies can practice legal murder. Since the legal system protects them you have to go around it. If necessary, contact the local news agency and see if your situation will be discussed on TV. Its not a question of shaming them as they are beyond feeling any shame. Bad publicity might hurt their incomes and this is something that they will respond to

Paul

Paula O 07-28-2017 02:41 AM

Re: Insurance Frustrations
 
I'm so sorry you are going through this frustration and the scary scenereo of an insurgence company denying coverage of Herceptin and Perjeta, Tracy. Yikes! I hope you can get a hold of the right people pronto who can resolve this quickly for you and that there is no delay in your August 8th treatment. Please keep us posted.
Paula

sarah 07-28-2017 10:07 AM

Re: Insurance Frustrations
 
Traci, this is shameful and morally wrong. I hope you have someone to fight for you.
hugs and love
sarah

Catherine 07-30-2017 05:24 AM

Re: Insurance Frustrations
 
Tracy, no one deserves this anguish and frustration. I hope you have someone close to you to help you make these calls. Thank goodness the sisters here have some great advice. I learn from this site every time I visit. I am hoping and praying that your oncology office will go to bat for you. How about the insurance commissioner of your state? Keep a good log of everyone you talke to in case you need to sue Aetna later. Love and support coming your way. We are all behind you❤️

thinkpositive 07-30-2017 12:24 PM

Re: Insurance Frustrations
 
Tracy,

I feel for you. I have Aetna insurance also. I had no problems getting both drugs approved although I only received them for a year. This is the standard of care for non stage 4 cancer. What is the reasoning for them denying coverage? It seems that the standard of care for stage 4 is that both drugs be given indefinitely. It certainly seems that this is a medical necessity. They need to give you a clear reason why they are refusing to pay.

I bet you will get these drugs covered. Somebody must have made a mistake. I remember getting a call from an Aetna employee (she claimed to be a nurse) early on in my diagnosis nd asking me if I was told I was "terminal". I was shocked and I had to convince this Aetna employee that I WAS NOT TERMINAL.

Good luck to you Tracy. You don't deserve this!

Take Care,
Brenda

MaineRottweilers 08-05-2017 09:37 AM

Re: Insurance Frustrations
 
Had a talk with Genentech and am working on getting them to float me my vials until we can get this mess straightened out. Still getting no where with Aetna though my oncology office is on point with them. I have written both, Maine's Senators and both Congressman too as well as my local representative and Maine's AG. Maine's AG and my local rep are the only ones to have responded so far. They both directed me to the Insurance Commissioner. I am still frustrated. I don't understand how Aetna can adjust the formulary to preclude standard of care medications.

Thanks for all the good ideas and support. I will keep you posted.

SoCalGal 08-24-2017 06:50 PM

Re: Insurance Frustrations
 
I just saw a study online, thru clinical trials .gov that was a generalized targeted therapy study. I cannot seem to find it - it was in the last couple of days. It was shared on FB, thru maybe?? Army of Women. It was a study of different targeted therapies, very broad based, I for sure recall the her2 arm was just herceptin and Perjeta. I'm very foggy this week, but maybe you have better googling skills? I even tried to save it, but then got distracted. Hope you can find or ask your online community if anyone recalls the study. I'll keep looking, too!

thinkpositive 08-31-2017 04:10 PM

Re: Insurance Frustrations
 
Tracy,

I noticed on your signature that Aetna approved H&P through February 2018! So glad to read that. It just seemed completely unreasonable that they could deny treatment that is the standard of care for this type of cancer. It is so unfair that you've had to deal with this in addition to keeping yourself as healthy as possible. Stress like this isn't what the body needs.

Take care,
Brenda

Catherine 02-12-2018 10:43 PM

Re: Insurance Frustrations
 
Did you see in today’s news that Aetna doctors admitted they approve or deny treatment plans without reading medical files. They just read the nurses notes. I think an executive resigned after admission to the government.

Colleen 02-13-2018 09:51 AM

Re: Insurance Frustrations
 
Yes Aetna is in the news in California for doctors not reading patient files before denying or approving health care needs. I think this gives you more leverage to receive the "standard" treatment for her2+ mbc which is FDA approved! Keep at it! They do not have a legitimate leg to stand on for denying your access to "standard" care.

Donna H 02-13-2018 09:55 AM

Re: Insurance Frustrations
 
WOW.....this is so wrong. Insurance companies shouldn't have that kind of control over our health! Especially when they don't review the documents they should be reviewing. Keep fighting for yourself!

MaineRottweilers 02-15-2018 05:18 PM

Re: Insurance Frustrations
 
WOW! That is crazy. I was approved through February 9th. I had an infusion on 2/6 so I am expecting to gear up for battle for my next treatment. I should get info about the prior authorization this week.

No one should have to fight to get standard of care if they have coverage.

Lucy 03-07-2018 07:14 PM

Re: Insurance Frustrations
 
Did Aetna approve continued herceptin and perjeta (I hope!)?

MaineRottweilers 03-15-2018 01:52 PM

Re: Insurance Frustrations
 
They did until the end of my COBRA in April. I was all geared up to fight but it never transpired. Thankfully.

Lucy 04-03-2018 06:48 PM

Re: Insurance Frustrations
 
I don't want to get too personal here but are you losing insurance this month? If so, what happens to your treatment plan?


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