How to complete a successful tier exemption appeal
I am trying to appeal a recent tier exemption request. Humana. Drug is Xtandi and will cost a whopping $12,000+ a month. Humana will pay about $9,000 without the exemption. I will be responsible for a bit over $3,000 a month for the drug, more that $36,000 a year.
Xtandi is a specialty tier drug level 5.
Because wording is so important I want to make sure I get the appeal right after being rejected. Has anyone had experience / success in this area?
Hi
. Sorry you are having this issue with insurance coverage. I have some experience with appeals letters, but I must admit that none involve cancer treatment (my wife has a severe form of an autoimmune condition diagnosed at two). I want to share with you this page from the Patient Advocate Foundation on things to include in an appeal letter: https://www.patientadvocate.org/explore-our-resources/insurance-denials-appeals/things-to-include-in-your-appeal-letter/. One of the things mentioned that I will note is the need to have your doctor provide a letter of medical necessity for the treatment in question. Our experience has been that working closely with the doctor to make sure you are on the same page can be a great benefit. We often did research to find the medical articles to help make the case and shared them with the doctor. Finally, be relentless. We have taken appeals to the state healthcare ombudsman. Hope this information is helpful and please feel free to keep us posted on how you are doing. Best, Richard (ProstateCancer.net Team) Thank you! I will be sure to read the link. I just got back from the doctors office and they are very cooperative. I have our doctors supporting statement / letter of medical necessity with back up "evidence". I will touch back and let you know how we made out.
Hi
, I am working with 4 prostate cancer patients who are asking the NIH to permit low cost generic versions of Xtandi/enzalutamide on the market, because the price is not reasonable. The drug was invented at UCLA on grants from the US Army and the NIH, and the price is far lower in every other country. It would be very important to have the NIH consider your story. The NIH says it will make an initial determination about whether or not to proceed within one month. This is an article about the case in Statnews. https://www.statnews.com/2022/01/03/march-in-rights-protect-prostate-cancer-patients-from-excessive-drug-prices/ Thank you, I will read the article. I also contacted Xtandi directly. It appears that they reduce or eliminate the cost based on income and coverage. Income below $53 a year (exclusive of SS benefits), no coverage or commercial coverage they help you. Most of the folks who take this particular drug are on Medicare and have part D (drug) coverage (like we have through Humana). Hard working middle class pays again. This is not excessive, this is insane. I would be more than happy to share my story.
Not sure how best to connect, unless I am allowed to share my email address. If this works, let me know, https://www.keionline.org/jamie. thank you. Xtandi did contact me re my request, forwarded them some info they needed. Hope to hear back sometime this week. Will update when I have one
It is amazing the amount of paperwork we have to go through to get some help. Hopefully at some future date and time we will all have an approach that works vs one that promises much ,sounds great but never generates real benefits to patients.
