Tips for Insurance Rejection?

My insurance company rejected covering a drug that my doctor wanted to use to help combat fatigue. They labeled it as “experimental” though it has been used for 10+ years by many cancer doctors for just this very thing. I tried to fight it, but ultimately failed. They stood firm.

Any tips for future rejections?

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Sorry to hear that Jeff. I have no doubt we’ll have lots of tips from fellow patient leaders as we’ve all faced this at one point or another as patients!

Have you gotten your doctor involved? Sometimes your doctor writing a note to insurance can help big time! I’ve also learned to appeal everything. They seem to always say no the first time, but never give up, try again and it can be a completely different outcome.

This also may be a helpful resource: https://mypatientrights.org/

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Hey Jeff! I’m so sorry this happened to you – it’s beyond frustrating when you have to fight to take care of yourself. If you’re really keen on trying the treatment, I might look into a copay assistance program who can help you cover the full cost. OR sometimes pharma companies offer programs to help patients reduce the cost when their medication isn’t covered. And, as Kristen mentioned, I think having your doctor write a letter of necessity is a great call (if you haven’t done it already).

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There are people who are paid to go over insurance bills for third parties & find billing errors, negotiate the cost of those bills lower etc. Have you reached out to them for any ideas or advice?
Also sometimes a hospital’s ombudsperson / patient advocate might have leads or useful input.
And potentially social workers with experience with health care institutions might be helpful (my hospice social worker was AMAZING at negotiating with all of them, from the US Veteran’s Administration to private home health care assistance providers when I was too exhausted to fight for my father).
Would a second opinion from another doctor (like say a palliative care specialist) shore up the first doctor’s opinion & recommended drug choice & possibly overcome the insurance company’s denial? (Palliative care is hot lately because among other things it is more cost efficient AND also produces happier patients & their families as well as better outcomes overall). Ask the doctor to write you a referral to see someone in palliative care with this drug & a second opinion in mind.
You need to work your network of contacts you have grown since diagnosis & treatment / management then have you contacts work their networks & so forth.
Persistence is key here.

I wound up using one of those prescription card companies (many advertise on TV) and no insurance. My out of pocket wound up being about the same as if insurance had covered it. But the process was frustrating. My insurance company (which hasn’t changed since the first time I took the SAME meds 10 years ago) would not entertain an appeal.