14 replies to this topic

[lnadal]

Hi!  I haven't posted in a loooong time.  Many heartfelt thanks to all who do.

This is a "heads up" about legislation that may be coming to your state. I recently discovered that Washington State changed coverage for all drugs classified as "oral chemotherapy".  This change will be a great help to some, but has unintended consequences for many of us. I discovered this when I showed up to pay my $20 copay for Gleevec at Walgreens only to presented with a bill for $1384.42!  This is due to a recently passed bill to help those who are taking oral chemo drugs that kill cancer cells and can be injected or given intravenously.  While Gleevec fits none of these characteristics, it is still classified with the other "oral chemo" drugs. This bill switches all oral chemo drugs, and Gleevec, from my prescription benefit into my Medical plan which has a $1500 deductible.  Luckily, I am blessed to be working and can pay it, although it certainly makes my budget tight for awhile!  The Washington State Insurance Commission representative felt that Gleevec may be wrongly classified and I have filed a complaint. 

You may want to check with your state legislators to make sure that any legislation in your state has the right language before it is instituted and see how this effects your health plan (mine is Premera Blue Cross). I have no idea how this impacts those on Medicare.  Here is a statement from Novartis at a hearing before this law (Washington State Bill 1517) went into effect: 

"•          Novartis Oncology supports language that improves patient access to oral anti-cancer medications, but feels parity may result in unintended consequences. It states that their oral cancer drug, Glivec, is already adequately covered under most pharmacy benefits and that parity would result in a large increase in out-of-pocket costs for many patients. Novartis recommends specific protective language be added to the bill to prohibit movement from the pharmacy to the medical benefit."

Apparently, this is an initiative that many states are looking into. I plan to talk with someone from Novartis next week.  Blue Cross told me that they don't classify drugs, something called "Medco"

Thanks, Lynn N

[CallMeLucky]

This is one of those cases where what benefits some hurts others.  In many cases, Rx plans have high deductibles, or more concerning, they cap out with an annual amount and anything over that has to be paid by the patient.  For those individuals, getting the Gleevec covered under their major medical is a good thing because in most cases it will provide them with better coverage.  The interesting thing is, and not sure how this works out for you in particular, is that most people with CML will hit their deductibles usually pretty early in the year due to lab tests and oncologist visits.  I can see where from a budget perspective getting caught off guard in January with having to pay the deductible unexpectedly could be a problem.  By the end of the year, however for a lot of people this would work out in their benefit.

It does not surprise me that Novartis supports people having to pay for their TKI drugs through Rx plans.  If Gleevec is covered under major medical, Novartis is going to get a lot more pressure from Insurance companies on lowering the price.  I suspect that Novartis' assertion that Gleevec is adequately covered by most Rx plans is a statement that many CML patients would contest.

[pamsouth]

My situation is a little different, regarding the language of chemo drugs and target cancer drugs. This is not in regard to paying for the drug but in regards to paying for the oncologist for cancer patients who are on oral target drugs (TKI) although the two being, 1. the drug code 2. the oncology visit code are intertwined, to pay for the oncology visits.  That is what I have been trying to get across, how we use or change the language of oral targeted drugs and their codes ( I understand why from Trey that the term chemo is incorrect for Gleevec as it is not a chemo, but a target drug.)  As chemo kilsl all cell and target kill a particular cell, I get that.

However I live in Indiana but our insurance is from another state, Blue Cross of Michigan UAW RETIREE.  My insurance has been allowing me (for 6 years) a broader interpretation of the code V67.2 then just chemo but also to include targeted Drugs which will allow payment for 3 follow up visit to the oncologist, Which by most insurance companies, is normally only allowed to use this code v67.2 for cancer patients who are on infusions of IV Drugs, to use this code v67.2 as a chemo. for follow, to pay, for the oncologist visits, The ins pays up to 3 onc visits per 30 days, with a v67.2 chem or target drug.  When I went to another cancer center for a 2nd opinion and also in the process of changing oncologist, the new cancer center financial / billing dept, was not familiar, with using this code v67.2, to pay for office visits for patients who are on a targeted drug, as most insurance only refer to V67.2 for chemo infusions.  However again, my insurance Bl Cr of Michigan has broadened the language of interpreting the code of V67.2 not only for iv infusion chemo, but for targeted cancer CML & and target drugs such as Gleevec, to allow the ins to pay for 3 follow up onc visits.  Not for the drug but the Oncology visit, but it must have the code V67.2.  I had to jump thru hoops for 2 weeks to get the financial director and their billing team to call my insurance company, they just kept passing me around you know in the endless cycle of the same people.  I finally got a call from the cancer center a couple days before Christmas that the financial director called my insurance and got an approval.  I don't why it is so hard to get the billing to call the insurance.  Some think it is fraud because other insurance in Indiana will not use the same interpretation or language for this code v67.2 so that my ecologist visit are paid.  However in the meantime I did a dispute when I got my EOB as it was turned down for wrong coding.  They, Blue Cross has 60 days to answer me by mail. Even though the financial director of new oncologist has gotten the Ok from my insurance and resubmitted the claim. I am waiting to get a letter from the Insurance dispute board and the EOB as paid.  So on my next oncology visit I can take it with me, as sometimes when you go back for another visit you get new people who are not up to speed,

PamSouth

[pamsouth]

Our deductible and out of pocket went up several hundred dollars, now at $1700.0  per year for my husband and I.  Also we pay cobra or dental and optical, plus we pay part of our monthly insurance premiums.  However at the moment I am only paying $20.00 co-pay month for my 30 day suppy 400 mg of Gleevec.

Insurance has not paid doctor visit in the past but this year they will pay primary doctor only up to 4 visit.  The only way I get them to pay for the oncologist is to use the V67.2, (which by most insurance is only allowed to be used on a chemo drug) but again Bl Cr of Mi Uaw retiree, has allowed this code to be interpreted for target drugs as to pay for up to 3 onc vist in 30 day period.

[jrsboo]

Thanks Lynn,

Will have to check into this, I am in WA, have Premera, and use Medco/Accredo for my sprcyel.  I don't think I have a deductible for health care though, husband works for the Railroad and has amazing benefits.

Will report back anything I find.

Caroline

[jrsboo]

Well, a quick call to Accredo later, she says I am still covered as before, there may be some new kerpoodle with getting a 90 day supply v. 30 day supply, there was some odd language about only getting a 30 day supply without there being an 84 day window.  Not sure what that meant. 

Hoping to decrease the dosage to less than 100 mg/day at next appointment next week anyway. 

Thanks again,

Caroline

[pamsouth]

My prescriptions goes thru Medco Accredo, However are health benefits are held in CHRYSLER UAW TRUST, which contracts Blue Cross of Michigan (we live in Indiana) and for prescriptions Medco Accredo.  About a year ago the UAW TRUST contract with Medco went from a 90 day supply to a 30 day supply and not much turn around.  In December also get a letter that I have to take to oncologist and verify that I still need TKI Gleevec, even though I see her ever 3 months and she fills out the prescription.  I called the UAW & they said the med's were costly and if for some reason I didn't need them they didn't want to get stuck with paying a 3 months supply.  I thought a 30 day mail order was a lot more money then a 90 day, that is per pill, but I'm not sure about that anymore.

PamSouth

[LivingWellWithCML]

This is definitely an issue for many.  I'm pinging some inside contacts on this legislation to see what's up.  I'm with BCBA of GA and my prescription drug co-pay benefit is quite good for Gleevec, and I don't want it to change to a medical benefit (in my case).  It seems like the legislation needs to be worded differently to make sure that TKI coverage falls under the **cheaper** of the two plans for a patient.  Yes?

[CallMeLucky]

Most med plans have an out of pocket max for the year.  In all the plans I have seen and dealt with, having TKI covered by med plan would wind up being better by the end of the year, although it would often cause a large payout in Jan with the later part of the year being 100% covered, so that becomes a budget issue for some.  Also it is certainly possible for this to be less beneficial to some people depending on how their plan is written.  For some this is a bigger issue because there are lots of people with major medical, even if it is just catastrophic, but not a drug plan.  It has been hard to get Rx coverage if you are not getting it through an employer.

I would like to see some info on the Washington state changes to understand if this is something unique or if they are just getting on board with what has been known as chemo parity.  If this is parity, then it is similar to what has been enacted in many states.  Recently New York passed their parity law.

The thing to keep in mind is that state laws do not govern group plans.  A lot of people are on group plans which are governed at the Fed level by the Department of Labor.  So if you are on a group plan, nothing will likely change until the parity issue gets taken up by congress.  Unfortunately most of those crooks are being paid off by the insurance companies who don't want parity, not to mention if they pass parity at the federal level, that would mean that people on Medicare would no longer go through Part D to get their medication, it would be covered directly under medicare, which would be a huge benefit to older people battling CML.

[hannibellemo]

CML,

That is my situation exactly. I don't have a drug plan at work, all prescriptions fall under major medical which works out quite nicely for me. I put $1500 in my Flex plan every year. $1,000 for out of pocket max and $500 for eye exam and glasses. Jan1 I pay for my Sprycel (up to my out of pocket max of $1,000) with my Flex debit card and I don't pay another cent for the rest of the year.

While this is a very good deal for me it is indicative of how screwed up our health care is!

However, my husband is contemplating a promotion that would take us to Albuquerque, NM. His insurance is not as good as mine and it costs more, too. He has $1,000 deductible/$3,000 out of pocket per person (up to 2), mine is $400 deductible/$1,000.... I'm going to have to put pen to paper,  (not really, I'll use Excel) and figure out what this move will cost us in terms of health care costs, not to mention the loss of my income.

Sigh, I miss the good old days when a move could be predicated on "Do we want  to live there or not? Hell yes, let's move to Albuquerque!" At least that would be my reaction if I didn't have CML and all the insurance baggage that goes along with it!

Pat

[lnadal]

Here is the link to the Washington State law.   http://apps.leg.wa.g... Bills/1517.pdf 

Here's the link to a hearing about the law.  http://www.doh.wa.go...s/OralChemo.pdf

It seems like this will be great for some and a problem for others.  Thanks, Lynn

[pamsouth]

Inadal,  thanks for the links.  I was wondering how many states and legislators are aware of the plight of cancer patient, especially those that are on oral targeted cancer drugs.  Some insurance will pay for 3 follow up oncology visits, per ever 30 days,  if you are on an chemo infusions, but ins will not pay follow to oncologist office visit if you are are on an oral cancer targeted drug.

PamSouth

[hannibellemo]

PamSouth,

That is not true of all insurance; I have no limitations on the number of times I see my onc. But the fact that we can't expect the same coverage from any insurance program is, dare I say it again, just another problem with our health care in the US.

Pat

[CallMeLucky]

Thanks for the link.  This is pretty much what I expected and falls under what is commonly known as Chemo parity.  A good number of states have done this and I suspect more will follow.  But as stated before and as noted in the documents, this only applies to state governed policies.  Good for Washington state workers, and individuals who work for smaller companies where they have actual insurance vs a group plan, or if it is a group plan it is for a company that is incorporated in Washington and governed by state law.  Large companies fall under federal guidelines.  Hopefully some day the fed will catch up and we can have equal and affordable coverage for everyone who needs these very expensive drugs to live.

[WoofWoof]

I have been an advocate for this both on a state & federal level. I believe that at this time fourteen states have passed a chemo parity law. There is also a Federal bill H.R. 2746:               Cancer Drug Coverage Parity Act of 2011. Please contact your representative and ask them to cosponsor this bill to get it going:

http://www.govtrack....?bill=h112-2746