Herceptin and Insurance

[stacyphillips]

I'm new to this board so let me apologize if this topic has been previously discussed.

I was diagnosed in 8/04, stage III, er/pr negative, her2 positive, tumor 8 cm. I had 12 weeks of chemo first to reduce lump so that I could have a lumpectomy (epirubicin, taxotere and gemzar). I had a lumpectomy on 12/1/04 with 9 nodes removed with 1 positive. Didn't get a clear margin so I had a re-excision, still no clear margin. I had a mastectomy on 1/28/05 and started another 12 weeks of chemo (taxotere and gemzar) at the beginning of March. I had TRAM Flap reconstruction on /6/905 and will finish radiation next week. My oncologist has me scheduled to start Herceptin in a couple of weeks, every three weeks for one year.

He is prettty sure that my insurance isn't going to pay for the Herceptin because I'm not stage IV. But, I will be his first non stage IV patient to get Herceptin so he can't be positive. I would so appreciate any information, feedback or personal stories from those of you in the same position that I'm in who are receiving Herceptin, or those of you who know of someone.

Thanks for listening,
Stacy

[Lisa]

Since Herceptin has now been approved for Her2+, node pos women, several women here are getting insurance paid for the treatment. I'm sure they'll respond for you.

And WELCOME!

Love and light,

Lisa

[sassy]

I have Blue Cross/ Blue Shield in Virginia and they are paying.

Sassy

[Rhonda4]

I start my first Herceptin (1 every 3 weeks) tomorrow and I "assume" my insurance is covering it (Dx 2/1/05, Stage 1 (1.6), Er/Pr-, Grade 3, no nodes, Her2neu+) as my doctor has ALWAYS been conscience as to what meds, procedures, etc. are covered my my insurance (Priority Health HMO in Grand Rapids Michigan), but he is the director of all the cancer services for the main medical facility on the western part of Michigan so he may have finagled (sp) it somehow. I hope it is covered for you too.

[LindaBL]

Stacey:

I am new to this board also.

My diagnosis was 2.4 cm IDC, grade 2, ER, PR and Her2 positive, NO NODES, and I finished chemo December of 2002!

In May of this year, more than two years after I finished AC chemo, I decided to start Herceptin.

My insurance company, BC/BS of Pa, approved payment with no problem, the day my doctor submitted the claim.

I have had two Herceptin treatments on the every three week plan. Unfortunately, I have also had all the minor side effects--headache, chills, fever, and diarrhea. I'm hoping they will get better with future Herceptin infusions.

Linda

[Janet/FL]

I am Stage 1, small tumor, node negative and began Herceptin/Taxotere Aug. 8, 2005. I was diagnosed in November, 2004, lumpectomy followed by radiation that ended this March. I declined AC therapy. According to BlueCross, they will pay for Herceptin. I have my fingers crossed that it will go through without a hitch.
Janet

[Laurie S]

Hi Stacy, I am stage 2 and am just finishing up 12 taxol/herceptins and will continue on herceptin for a year. My insurance Healthpartners in Minnesota is also paying for the herceptin. Good Luck! laurie

[mts]

My insurance paid and I am Stage I, node neg. My last chemo was in March and I began Herceptin July. My old onc said that my ins would not pay and that I would pay "what he pays" which was $6000. I then found an onc that said there was no reason for the ins not to pay. I have a new onc. I received my first estimate of benefits yesterday (I have BC/BS of Florida) and the ins was billed $2800 for my first infusion (that included all labs, etc) and the ins paid $1900. I don't owe a thing. My onc is happy and so am I. I cannot understand why one onc requests so much more than another. Ridiculous.
It is my understanding that if a drug is FDA approved, it is covered. Herceptin is FDA approved... and it does not matter what Stage you are.

I know there are many women on this website that pay more out of pocket becasue of lack of coverage. They could fly to Orlando, Florida, stay in a nice hotel, get an infusion and still come out ahead.

Maria

[Janet/FL]

Maria writes: My old onc said that my ins would not pay and that I would pay "what he pays" which was $6000. I then found an onc that said there was no reason for the ins not to pay. I have a new onc. I received my first estimate of benefits yesterday (I have BC/BS of Florida) and the ins was billed $2800 for my first infusion (that included all labs, etc) and the ins paid $1900.

Hi Maria
Was your first onc with the Florida Cancer Specialists? That is exactly what they told me. I am at another place and supposedly my insurance (BC/BS of Michigan) will pay. (Just had first treatment 8/8 so don't know yet). But I did forget to ask if they were particpating providers. D*amn. It seems like there is always an insurance problem. I will have to call them tomorrow. I know there was a problem with BC/BS in the past with them--a local hospital--but supposdedly they got it resolved. And I think the people in charge think I am totally covered but I started worrying about it earlier in the day so I had better call now that you mentioned it since my MRI wasn't covered but my Neulasta shot at the office supposedly is.

Alaska Angel--is there a chance you are covered also?

Janet

[mts]

Janet/FL :

My previous onc is in Sebring (where I live). I really feel he tried his best yet, does not deal with any other HER2 patients. Everytime I went for my chemo I was by far the youngest one in there (42) and his billing department very "sure" insurance would not pay... The onc I go to in Orlando is with Hematology & Oncology Consultants. I drive 80 or so miles for him, but well worth it.

Where in Fla are you?

maria

[Janet/FL]

Hi Maria
I am in Naples. I don't feel as kindly to my former oncologist as you do to yours. Between not letting me get Herceptin unless a major cancer center would recommended it for me, even though he felt I should have it, saying I would have to pay up front and it would be my problem to get reimbursement, and saying that my Blue Cross would not pay for shots in the doctor's office was just too much. My current onc sure ain't perfect--But dollar signs and lawsuit worries are not all he thinks about! At least that is JMHO--just my humble opinion.
Janet

[stacyphillips]

Maria,

Did your previous oncologist's billing department ever even send in a claim for Herceptin, or did you switch before they tried based on their attitude of being "sure" insurance wouldn't pay? I too am one of the youngest patient's at my onc's office, 44. I'm scheduled to start Herceptin on Aug. 29th and I'm starting to wonder if I shouldn't talk to another oncologist before then. I'm being treated in the small city that I live in, but wonder should I talk to someone in Nashville, possibly at Vanderbilt? (Only about 30 miles from me) Any input would be greatly appreciated.

Stacy

[sassy]

Stacy,

I posted before, but didn't give much info. I too am early stage and what I consider young (46, 45 at diagnosis). My insurance, BC/BS Virginia is paying. I get treatment in North Carolina. When the question of coverage came up, the staff at my center told me that they had people to specifically handle that. They called prior to my first treatment and were told by the insurance company that they would pay. I did not have to do anything. Can you check with the staff at your treatment center, or if your insurance is thru your employer, go to your HR person and have them get your agent involved in checking. If it is private insurance, go to your agent for assistance if you cannot contact your insurance company directly. You should be able to get an answer from your insurance company despite who does your treatment.

I was going to have my treatment at small town nearby, but opted to switch to a larger Cancer Center for several reasons. I drive two hours for weekly treatment, but feel that every mile has been worth it even with the price of gas going sky high, working full time and staying busy with my husband and two teenage boys. I have never had any regrets about switching and have had only positive experiences with staff, billing, treatment and very personalized attention. You may have a very different experience at your small clinic, but being comfortble and confident in the people who are treating you is a vital part of your treatment.

Sassy

[LindaBL]

Stacey:

My oncologist's office did all the work inquiring about coverage for Herceptin. I learned the next day that here was no problem with BC/BS. It helped me decide to start treatment. Recently, I received the EOB from BC/BS---all, of a very expensive bill, is covered.

Linda

[mts]

Stacey- My 1st onc is in a small town (where I live). I go to Orlando (approx. 75miles one way) for the "expert" stuff; including my Herceptin. I still maintain a patient relationship with the local onc because I believe in having someone at least close-by in case I need bloodwork or other meds and the local guy is good in those aspects.
As for the insurance, the local guy's billing department did call the insurance company on my behalf. THey were told that as long the drug was FDA approved, then it would pay. Yet, the ins company would not put that in writing. This was the reason why they wanted me to pay upfront. I am sure I was the only Herceptin patient and the office was not willing to take the chance of not getting paid. I got really tired of back and forth with them and went to someone that gives Herceptin all the time. That's how I ended in Orlando. The onc in Orlando insisted that insurance would cover me because "he gave Herceptin all the time". What a difference! Yes, it does help to have an onc that has Herceptin experience and that treats BC on an every day basis. In the end, my comfort level is better with the Orlando guy , not because of the money part, but mostly because of his level of experience with cases similar to mine (although the $$ part does help!).

Make sure your onc is participating provider in your insurance network. Otherwise, the insurance might pay -only not as much and you will have to pay the remainder.

Also, it NEVER hurts to get a 2nd opinion. Seems like a lot of women don't want to switch oncs because of "loyalty". My motto is never to "fall in love" with an onc. Good luck!
Maria