Insurance coverage for Bi/Trimix and ED drugs (Levitra, Cialis, Viagra)

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41diagnosed
Regular Member


Date Joined Jun 2007
Total Posts : 176
   Posted 5/2/2008 2:10 PM (GMT -6)   
I am sharing this because I have read on this site posts from members comparing how much they are paying for their ED meds from specific pharmacies. 
 
Be aware, if you have insurance, you should only be paying your COPAY amount.
 
First, my copay for tri or bi mix is $10.  When I started, it was nearly $60.  What I discovered was that the Pharmacy was billing me under a different NDC code than they were billing my insurance.  They were collecting more from me and more from the insurance company than they should have been, but were doing it because with compound drugs, there is more room for playing games.  Compound drugs include more than one drug (seems obvious), so they are trying to compensate themselves for what they believe they should be paid.  Actually, it's unethical and probably illegal for them to do this, but they are getting away with it.
 
What I discovered was to get properly reimbursed, the Pharmacy needs to submit a Compounding Worksheet to the Insurance company who sets up the compound drug in their system so that it gets adjudicated at the proper copay amount....mine is $10.  SO why don't they do it for you without your asking them to?  Here's why.  The Pharmacy was getting reimbursed twice, once by me and once by the insurance company under two different drug codes both of which went into the medication!  Make sure this is not happening to you.  Simply call your insurance company and ask what NDC code was claimed for your prescription by your Compounding Pharmacy and compare that to the NDC code on your prescription from the Pharmacy.  They should match and so should the copay amounts.
 
Also, I got a box of 100 syringes and paid the same co-pay as a box of 20. Had I not asked, no one would have told me I could get more at one time.  I would have paid 5 times as much for syringes ($50 instead of $10).
 
For the Levitra, my doc prescribed a qty of 12/month, which is 3 per week.  My Insurance company told me they cover only up to 6/month.  You have to push past the customer rep level and get to a Supervisor to get resolution.  Be aware that it is in the insurance companies best interest to tell us "no" to covering the meds for erectile function rehab. 
 
Don't back down when they tell you they don't cover the qty prescribed to you by your physician.  Ask your doctor to provide a letter such as Dr. Catalona, my surgeon, provided me that quotes clinical studies to support the use of ED meds for earlier return of sexual function after PCa surgery.  Many or most of the insurance companies have not updated their reimbursement policies to acknowledge these recent studies and therefore continue to erroneously decline or underpay claims presented to them by PCa patients.  
 
For now, I've received reimbursement approval for the full dosage of Levitra prescribed by my doc which will be covered by my normal copay.  This approval is in place for 6 months at which time they wish to "review my progress". I am curious how they intend to do that???
 
It's not a permanent solution as of yet, but I'm making progress.
 
Remember, the purpose of the ED drug regime post surgery -- which most of us didn't require before surgery or treatment -- is to produce increased bloodflow to the penis to promote healing of the nerves and tissues that promote erectile function.  More oxygen is proven to increase healing time.  Remember to tell this to your insurance company if they decline paying your claims for ED drugs. 
 
I hope this helps some of you who have had your claims declined by your insurance company or who may be overpaying without knowing it.


 
42 yo. now
 
5/07 PSA 4.65 at routine physical
6/07 biopsy positive for cancer...Gleason 3+4...diagnosed at 41 y.o.
6/07-9/07 manic research and interviews with physicians across the country in search of the "right" decision.  I went to Mass General in Boston, Loma Linda, University of Chicago and Northwestern.
9/17/07 - Radical Retropubic Prostatectomy Surgery at Northwestern Memorial in Chicago by Dr. William Catalona.  Thankful the father of the PSA test was right here in Chicago.
 
Post op pathology was Gleason 3+4 with negative margins, no seminal vesicale involvement, no lymphatic or vascular invasion, bladder and urethral free and tumor volume was 5% of 27.3g.  
 
9/27/07 - Catheter removal...let the games begin...
 
12/07 - Threw out the pads.  I only had to use 1 pad per day for protection against minor drips. 
 
I started Trimix 8 weeks after surgery with success.
 
I hope someday I won't need injections, but I hope more that my PSA stays at 0 forever.
 
 
 

Post Edited (41diagnosed) : 5/2/2008 5:17:39 PM (GMT-6)


DanmanBob
Regular Member


Date Joined Feb 2008
Total Posts : 467
   Posted 5/2/2008 5:14 PM (GMT -6)   

Interestingly, I just linked moments ago a Q&A on incontinence from your urologist.

As for the meds, I order Viagra from alldaychemist.com....at about 56 cents a pill.

Have not tried to get reimbursed for the bimix, but just got it recently.

Thanks for sharing your experience.

DanMan Bob


Danman Bob, Born 1951
Nerve-sparing, open prostate surgery November 13, 2007
Gleason score 9, PSA 14; Biopsy result - 9 of 12 sticks showed cancer
Post-op pathology stated that cancer was confined to the prostate
Unrelated surgery January 2008 delayed incontinence recovery, which is now showing good signs of improvement (fraction of a pad a day as of late April 2008)
100 MG Viagra 3 times a week beginning December 2007
Osbon Erec-Aid Esteem manual pump for therapy beginning mid-February 2008
30 MG papaverine/1 MG phentolamine bimix injections beginning late April 2008
Five week post-op PSA 0.2, five month post-op PSA 0.1, next test August 2008


KrisP
Regular Member


Date Joined Mar 2008
Total Posts : 162
   Posted 5/2/2008 7:01 PM (GMT -6)   
For me, as of now I'm only on Levitra 20mg every other night and this cost me $80.66 and Employer cost is  $322.63 for a 90 day supply (total of 36)
Biopsy done 3/2008
Pathology report: Gleason 6 (3+3), involving left lobe
DRE=15gm with indurated left base and mid prostate
Cores positive: left base medial, left base lateral, left mid medial and left mid lateral (4 of 12)
Clinical stage t2b.
Prostate Carcinorna 185
DaVinci Surgery on 4/21/2008 in Austin by Dr Randy Fagin.
Pathologist report upgraded to a Gleason 7 (3+4)
Clinical stage upgraded also to a T3a
Margins Clear

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