Help for a friend - Insurance question

[lisajones4]

Hi everyone. Hope you are enjoying the 4th of July weekend. I need some advice for a friend who has leukemia. Her insurance company is fighting her on paying for the chemo drug she is taking. They consider it "experimental." (Unfortunately it is her second line of defense as the first one was damaging her liver.) Do any of you have advice on how she should negotiate with her insurance company? Thanks!

Lisa

[ElaineM]

Can the drug company that makes the chemo be of any help? Some drug companies have programs to help with the cost of medicine.

[hutchibk]

Alice is right about access programs. Definitely check into that as well!

Is the chemo she is getting truly experimental? Is it approved by the FDA as a standard treatment? Her doctor and/or the business office where she gets treatment should be able to shed some light on it for her. Or, better yet, is there a patient advocate nurse at her treatment center who can help her truly figure out why they are denying it. One question to ask is if it is a treatment that medicare covers. If so, most insurance companies follow medicare mandates (which can occasionally work in favor, and can often work against...). If she truly finds out that she has a basis for appeal, the most important thing to do when filing the appeal is to immediately cc: the state board of insurance, and make sure the insurance company knows that they have been cc:ed. (Call the state board and ask who you send the copy of appeal to). This tends to light a fire under insurance companies to straighten up and fly right. Also, it could just be that they need a letter of medical necessity from her doctor in order for her treatment to be covered under the mandates of her policy...

[Joe]

I would suggest that she contact the Disability Rights Legal Center (http://www.disabilityrightslegalcenter.org/about/cancerlegalresource.cfm/)

Regarfs
Joe

[ElaineM]

Good ideas Brenda and Joe. I am also thinking that if all else fails she might be able to get some referrals to financial help from the American Cancer Society. Partnership for Prescription Assistance might be able to offer some advice or help too.

[madubois63]

You've got some good advice already, but I think the doc needs to go to bat. Sometimes just a little push is more than enough. She can't take the first line because it is damaging her liver. The insurance company needs to know it will cost them more money to fix her liver down the line that it would just to give her the second line drug (believe me). the doc should have social workers looking in to this along with the insurance staff. This is really not something your friend should be stressing over. My doc would just give me the treatment and let the rest of the staff get the approval. Do you know which drugs are under consideration?? Maybe I can find some info from my leukemia doc??

[hutchibk]

Also - call the Lance Armstrong Foundation patient support hotline:

866.673.7205

I believe they have advocates who can help you deal with insurance. They are more likely to help with these questions than the ACS, I think.