insurance refusing to pay for multiple sclerosis treatment

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markmajor
New Member


Date Joined Oct 2007
Total Posts : 5
   Posted 10/15/2007 2:24 PM (GMT -6)   
My sister is in her early 30's and was diagnosed one year ago with MS. She is a medical doctor and currently is in her training. Her doctor started her on avonex a year ago. She has not developed new symptoms but developed one new lesion on her one year follow up MRI. Her neurologist wants to start her on IVIG (my sister is scared of PML and wants to have children in the future) in addition to the avonex twice a month. Only problem is that the insurance company: empire blue cross , refuses to pay the $10,000 per month for the cost of the medication. Cellcept was a consideration , but working in a hospital, it is more of a danger to be immunocompromised. My parents are of retirement age and are ready to dip into their limited savings to pay the monthly cost of the medication.

Does anybody know of any other solutions? Is it legal for an insurance company to deny coverage like this?

uppitycats
Veteran Member


Date Joined Jun 2005
Total Posts : 2135
   Posted 10/15/2007 2:43 PM (GMT -6)   
markmajor said...
My sister is in her early 30's and was diagnosed one year ago with MS. She is a medical doctor and currently is in her training. Her doctor started her on avonex a year ago. She has not developed new symptoms but developed one new lesion on her one year follow up MRI. Her neurologist wants to start her on IVIG (my sister is scared of PML and wants to have children in the future) in addition to the avonex twice a month. Only problem is that the insurance company: empire blue cross , refuses to pay the $10,000 per month for the cost of the medication. Cellcept was a consideration , but working in a hospital, it is more of a danger to be immunocompromised. My parents are of retirement age and are ready to dip into their limited savings to pay the monthly cost of the medication.

Does anybody know of any other solutions? Is it legal for an insurance company to deny coverage like this?
Unfortunately it is legal for the insurance company to deny coverage for multiple treatments (both the IVIG and the Avonex) for the same illness.  For that matter, they could deny paying for any of it, if they decide to!.  You might want to check by the way..I think Avonex is a weekly injection, not twice a month.  Anyway -- another option is to check with the makers of Cellcept and see if they can offer some assistance. Some of the drug companies will. Or with Avonex. While that is likely the least expensive (around $1500/month rather than the $10,000!), maybe that will make a difference. (And be sure of course that you have those dollar amounts correct when you talk with the companies, as they'll want to check).  Maybe the hospital where she is working would be willing to underwrite some of the costs for her?
 
 
...I am not a doctor, nor health professional, and don't pretend to be one, here.....


markmajor
New Member


Date Joined Oct 2007
Total Posts : 5
   Posted 10/15/2007 2:55 PM (GMT -6)   
Thank you for your response!

Just to clarify - she is currently taking Avonex 1x per week by injection for one year and the insurance is covering that. Her neurologist wants to add on IVIG 2x per month in addition to the weekly injection of Avonex. The insurance will not cover the addition of IVIG. It is difficult for her to ask the hospital for insurance help, since she has already encountered significant prejudice from the limited number of coworkers she has confided to about her condition. One doctor actually told her that she is jeapordizing other patients and should tell each and every one about her condition! She does not suffer from any cognitive decline whatsoever!

pokey79
Regular Member


Date Joined Aug 2007
Total Posts : 144
   Posted 10/15/2007 3:31 PM (GMT -6)   
Wow it is amazing how healthcare facilties treat their less than pefect employees..Been down that road.Uh biogen has a a plan to help with the avonex.She should be getting regular calls from them ask if they can help..They try to make it possible and easy for people to stay on track with their medications.Is there anything her neuro can do to help??pokey79
diaganosed 1983
avonex once weekly
steroid infusion every three months for three days
mycoline three times a day
fosamax once a week
bladder meds. daily
calcium/multivitiams
synthyroid
 
 


markmajor
New Member


Date Joined Oct 2007
Total Posts : 5
   Posted 10/15/2007 4:06 PM (GMT -6)   
Her neurologist already appealed the insurance company twice and was denied by a neurologist used by the insurance company who has never seen my sister.

Empire used to cover IVIG but stopped accepting coverage for new patients who wanted to start this therapy. The people who were already on IVIG are allowed to continue IVIG and are covered. How can you justify reimbursement for some patients and not others?

uppitycats
Veteran Member


Date Joined Jun 2005
Total Posts : 2135
   Posted 10/15/2007 4:14 PM (GMT -6)   

Is it perhaps that they are denying coverage for BOTH medicines?  That is, if she would be on just one (either one) they've cover it, but because they're being asked to pay for BOTH of them, that they're balking?  If that's the case .. she should drop the Avonex for now, go on the IVIG, and then appeal to Avonex to cover their costs.  They do have a fund to help with that sort of thing.

Unfortunately the way the insurance companies work these days is that they don't see patients, they only look at the bottom line. . the dollars.  I'm sure somewhere there is an actuary that says it is "not cost effective" to pay for both meds, that there isn't sufficient evidence to support that treatment..at least not sufficient evidence from the insurance companies bottom-line point of view! That sucks, to be sure.  And they can (and often do) change their minds about what they'll cover..and not cover. Sometimes they won't continue to pay for meds for folks for drugs they'd covered in the past but have decided to no longer cover.  And again, that sucks. I'm sorry!

 

 


...I am not a doctor, nor health professional, and don't pretend to be one, here.....


markmajor
New Member


Date Joined Oct 2007
Total Posts : 5
   Posted 10/15/2007 4:25 PM (GMT -6)   
what kind of fund do they have?

Kimber
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Date Joined Jun 2005
Total Posts : 1852
   Posted 10/15/2007 4:31 PM (GMT -6)   
Hi markmajor,
 
   I was going to suggest appealing but I see that has been done already with no success sad Another alternative would be to talk with her doctor and see if the manufactor of the IVIG itself has some kind of assistance program. 
 
Kimber
 
Co-moderator for Multiple Sclerosis
 
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uppitycats
Veteran Member


Date Joined Jun 2005
Total Posts : 2135
   Posted 10/15/2007 4:56 PM (GMT -6)   
markmajor said...
what kind of fund do they have?
With the materials your sister got from the Avonex company, there should be a toll-free phone number for a nurse-representative-advocate person.  He/she should be able to talk with your sister to see if she might be eligible for either a reduced payment or a free payment for her Avonex.  The company works to help people who either have no insurance or inadequate insurance.  There are no guarantees, of course, that they will, but it's a toll-free call, so worth trying!
...I am not a doctor, nor health professional, and don't pretend to be one, here.....


markmajor
New Member


Date Joined Oct 2007
Total Posts : 5
   Posted 10/15/2007 5:31 PM (GMT -6)   
The problem is not covering the avonex and IVIG together. They will not cover the IVIG at all! Even if it is the only medication my sister is taking. The insurance company does not want to pay the 10 grand per month that is needed.

uppitycats
Veteran Member


Date Joined Jun 2005
Total Posts : 2135
   Posted 10/15/2007 9:56 PM (GMT -6)   
I'm sorry! Unfortunately they don't have to cover it, there's no "law" that says insurance companies have to pay for anything, and they'll figure out ways to maneuver around whatever the policy may have suggested they offer. I hope your sister's doctor can figure out some way for her to get it through the hospital.
...I am not a doctor, nor health professional, and don't pretend to be one, here.....

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