Insurer refusing payment of drug Rituximab

[bmichaelh]

Hello:

I have follicular lymphoma.

I have one more cycle after this last one.

My doctor has prescribed me the R-CHOP protocol.

One of the drugs part of this protocol (R)ituximab, insurance is refusing to pay for because the insurance company has deemed it as medically unnecessary.

According to the top rated Cancer Hospital as ranked by US News & World Report, (University of Texas MD Anderson Cancer Center, Houston):

The standard first-line therapies 
for follicular lymphoma are rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP)

https://www.mdanderson.org/publications/oncolog/a-new-era-in-follicular-lymphoma.h18-1591413.html

Insurance through your employer sometimes is not that great.

I have several options:
Appeal
File a complaint with the insurance commissioner office.
Get a lawyer

Thanks.

[vsrazdem]

1. R-CHOP is a standard cancer therapy. This is bullshit. Your MD should write a letter to insurance.

[TexasTowelie]

2. Option D

Be prepared for all of the above.

While it seems like the next logical step is file an appeal, I would go ahead and consult an attorney before proceeding with the appeal. If you have the financial means to do so, then having an attorney on your case at the beginning sends a powerful message to the insurance company that you are fighting for your life and don't stall my case. I would also be prepared to contact the physician that wrote that prescription so that he knows that his orders are being countermanded and if there is an alternative to the prescription available.

While you might not want to spend money for an attorney, keep in mind that the alternative might be that you won't be alive to spend it later.

Filing a complaint with the insurance commissioner will probably not result in the outcome you want in a timely manner. However, if the insurance board is getting a lot of complaints about particular health insurance companies then it might raise red flags so that other people may have an easier time dealing with the insurance company in the future.

[still_one]

3. Finish the treatment regardless, and appeal. You will need you physicians office to be

to be part of that appeal to state why this is necessary and required.

All the best, and take care

It isn't just the private insurance companies through one's employer that does this, Medicare does this also

Some of the problems I think are the bureaucratic paper pushers who go through a process without looking at the details involved, along with the insurance companies accountants hoping the patients won't bother to appeal.

I am taking a drug for occular inflammation, and every year I need to file an appeal to get approved in spite of the fact that it was appealed and approved the previous the previous year.

Unfortunately I think this is only going to get worse with such things like this coming down the road:


https://www.medscape.com/viewarticle/914238

[Habibi]

4. I would certainly file an appeal, but

can you also check with the drug maker for assistance? Also, the American Cancer Society may have leads to grants you can apply for. Good luck;please let us know how things are going for you.