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  • Lman
31 Oct 2022 13:56 - 31 Oct 2022 13:59
Replied by Lman on topic US Insurance
Hi Poseymint! Thank you for your excellent response!

I wonder if it might be better if you get your Nplate injections in a doctor's office.? I know thats the way it has worked for me. Is that an option? I didn't think it was approved to do home injections in the US. I have United Healthcare Medicare (which is different than your college insurance) and my Nplate Is paid for, but only because it is done at the cancer clinic. That would be billed under the "medical benefits". Mine is not covered under the pharmacy benefits as you mentioned. But yours might be different- your hematologist office would know.

That was an option though, but during my first visit to the doctor, he said there was another student which is receiving it at home, although his provider was not my doctor and he had only heard of him at their hospital. During the month they were asking for pre-auth (which was never required), the doctor also wrote a letter to insurance stating that I have been self-injecting for 3 years and he believed I should do since coming into the office every week is a huge burden on me and the hospital. They definitely have sent that letter to the insurance since I got a copy of it, but I don't know if they have taken this into account or not. And yes, initially when I emailed and inquired about UnitelHealthcare from J2796, they told me this is approved for administration in the office. Since as you know, for every shipment optum calls medical benefits, I have a strong feeling that this is gonna be ok since otherwise, UHC would not give ok to send thousands of dollars worth of medicine to a student :). The hospital nurse (after talking with optum and UHC) also told me it was ok to have it at home and she documented these on my chart which she told would be a legal document. And finally, what also made me confident was this:

Although not commonly self-administered at home in the United States, most of our patients can administer romiplostim at home after discussion with their insurer and training the patient. Home administration has been shown to be as effective as that by a healthcare provider ,  aob.amegroups.com/article/view/6335/html

I now believe chances are low that I get denied only because I administered at home, after all these conversations. I hope so!

I can't really answer your question about United Healthcare statement and what they mean by $0 paid. I think it means that you owe nothing? On my bills it says "amount paid to you" which is always $0. (because the money is going to the provider, not me). Not sure if thats what you are seeing on your bill. When I had Amgen First Step, Amgen paid my high deductible/max out of pocket which was $6000-7000 per year. I ran up that much in the first month because I need two vials per week. It was my max out of pocket, so after that was sorted out, I paid nothing for medical the rest of the year. But getting it sorted out was very stressful every year.

I also get two vials per week. Now that I checked the initial hospital bill (which was processed) more deeply, it seems the paid amount on the website bill is the amount that the insurance has paid, so we have paid = total benefits. In the case of hospital visit, the bill was $300 and the paid amount was like $100 and the rest, 300 - 100 = 200 was considered patient balance, which I had to pay out of my pocket, and that $200 was deducted from $1800 maximum out of pocket so now it is $1600.
What I just wanted to ensure is that as you said, what Amgen's first step is going to pay (on the very first bill, which would be more than my left balance of $1600) would now zero out my maximum of-pocket for the rest of the year, as you said. What I expect and want to ensure will happen is what Amgen is going to pay would zero out my out-of-pocket balance and I do not need to pay anything, rather than not decreasing my out-of-pocket balance so that I will have to pay the remaining $1600 out of my pocket, soon where the Amgen's $10000 annual limit was hit. I attached the bill maybe it helps to get the clarification.   drive.google.com/file/d/1PlZ-eKygqkHlm4jUSEXj_k4S1sN9Xvg4/view


And finally, yes. unfortunately, you will become an insurance expert going through all this :)  I hope it processes smoothly and my future work insurance is much better than this!

Thanks for your kind answer :)
  • MelA
31 Oct 2022 18:34
Replied by MelA on topic I have finally started the drug trial
Well shoot mrsb!   Is it possible you have the placebo - or is this a trial where everyone gets the real thing?
Makes sense to try Fostamatinib again.
  • poseymint
31 Oct 2022 21:47
Replied by poseymint on topic US Insurance
Okay, what I think "Paid $0.00" means is that the charges are still "Under Review". No one has paid anything yet so zero paid. It doesn't mean they are not paying, its simply under review at this time. That is normal. Insurance companies don't just pay bills of $11,000. quickly. They have to haggle a bit and get the balance down.

My guess is that the insurance will agree to pay a percentage of the $11,000., not the whole amount. Then Optum will agree to that reduced amount and they will settle on it. Thats just my guess, your experience may be different. In my case, my doctors office/hospital group charges the insurance a whopping $18,000. for 2 vials/500mcg of Nplate! Its crazy, my insurance refuses that amount and agrees to pay $3,500. My doctors office/hospital group agrees to the lower amount and everyone is happy. The hospital group gets a small profit because they are likely paying only $2000. or less for the Nplate.

Another thing I'll mention in hopes to clarify: Amgen doesn't pay for Nplate, only what YOU owe for Nplate. They are only helping you, not UHC. So the way it looks to me is that Amgen will pay $1600. and that is all. They won't hit the $10,000. mark or come near it. Optum said your first copay would be $1700. so as you said, your out of pocket max would be met in the first shipment. I found the Amgen co-pay card to be pretty simple and reliable, there was never any problem with them paying my bills.

I hope I'm right! I would feel bad to have given you the wrong information. But thats the way it has worked for me. Health insurance is a complicated and weird game. I guess if you can talk to someone at UHC, you might ask them to explain their bill and confirm that "Out of Pocket" means the maximum you'll pay. You'll know more in a few months. Hopefully it goes smoothly as possible. Good luck! ~p
  • mrsb04
01 Nov 2022 09:35
Replied by mrsb04 on topic I have finally started the drug trial
Mel
Every one is getting the real thing 
  • CindyL
01 Nov 2022 10:28
Replied by CindyL on topic I have finally started the drug trial
Aw, mrsb, that sucks!  I'm sorry you're going through that.  Fingers crossed that things start to improve soon.       
  • adamt
01 Nov 2022 17:34 - 01 Nov 2022 17:38
Replied by adamt on topic Something to take a look at.
Is anything he actually says in the video incorrect? I'm not all that interested in internet personalities but pretending like the medical establishment has anything to contribute at this time apart from giving people anachronistic treatments like prednisolone is wrong.
  • Chad89
01 Nov 2022 18:17
Replied by Chad89 on topic Something to take a look at.
That was my thought on it as well Adam. While I don’t think he had ll the info, the information he is sharing is backed by other doctors and studies. It’s nice that people are trying to look at the underlying causes instead of just throwing heavy medications at people.
  • MelA
03 Nov 2022 23:45
Replied by MelA on topic I have finally started the drug trial
Well darn it mrsb!
I hope your count improves!!
  • mcafiero
04 Nov 2022 10:49 - 04 Nov 2022 11:31
13 years ago I was diagnosed with ITP, and went straight into a remission after tapering off my first go at Prednisone. I always felt lucky about this. And I always felt that it could come back at any time. And this week it did.

After doing some research, it doesn't look like much progress has been made in terms of treatments. I'm seeing the same old stuff. I am seeing TPO-RA drugs like Eltrombopag (Promacta) for the first time.

Anyway, trying to figure out what's new. I feel I got pretty lucky going into remission after prednisone back in 2009. Would love for that to happen again of course, but that would seem extra lucky.

Thanks,
Mark
  • Lman
04 Nov 2022 15:44
Replied by Lman on topic US Insurance
Thanks!
I confirmed with Optum again (and had previously confirmed with UHCR as well). The first bill is now pending and let's see how would it unwrap.
And interestingly this time they told me my copayment is 0 and not I have a good feeling that it is getting fixed!
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