› Forums › General Melanoma Community › Opdivo /Insurance “Red Tape” @ MD Anderson
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studiodad.
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- December 7, 2019 at 10:32 pm
Hi,First time poster. Thank you to all that have shared their stories. This forum has been both informational and emotionally uplifting as I begin my melanoma journey at 33.
I am a stage 3B patient at MD Anderson and have been prescribed Opdivo. Overall I’ve been very happy with my treat at MDACC. However I’ve run into some “red tape” between my insurance and MD Anderson. Long story short, my medical plan through Aetna covers the medical costs to administer Opdivo, but the costs for the drug are carved out to CVS Caremark. The sticking point has been that MD Anderson has its own pharmacy, and “is not set-up” to work with CVS Caremark, even though CVS has been willing to simply be billed for the drug through MD Anderson. MDACC also do not allow the drug to be shipped to MDACC nor do they allow “brown bagging” for liability reasons. I find it a bit odd that such a large hospital and a large insurance firm can’t work out what seems to be a simple billing logistical issue. CVS has been clear that the drug is covered under my plan.
Luckily I believe I’ve found a work-around to receive the immunotherapy from Kelsey-Seybold, but it’s frustrating I’ll have to see another oncologist @ Kelsey-Seybold meanwhile still consulting with my MDACC doctors. I’ve also talked with a few 3rd party infusion centers in the Houston area, but they all have very little experience with Opdivo, so I’m not comfortable with it. I’m particularly concerned of the complicated logistics working between 2 hospitals if I were to progress.
Has anybody had similar issues? Any advise on ways to cut through this red tape? I’ve been in close contact with MDACC financial clearance, Aetna, CVS, and my employers benefits administration, but not optimistic that a resolution will be found anytime soon.
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- December 7, 2019 at 11:25 pm
Hi Steve,
If you can’t cut through the red tape, perhaps you can avoid it. I get all my scans, biopsies, surgeries, plan of care at MD Anderson BUT I have a local onc in my hometown who administers my infusions. My melanoma onc at MDA is perfectly fine with this arrangement. I think this happens quite often with patients from out of state. In fact, my local onc had a possible trial for me recently that MDA was not aware of, and my melanoma MDA onc was 100% in favor of doing it, saying it would not affect my standing with her at all. Going to Kelsey-Seybold might not be so bad, in other words. If it were me in your shoes, I would first go directly to your melanoma onc through the portal and explain everything. He/she might be able to get things moving in the right direction there with billing, pharmacy and all of that. If not, then just run it by him/her and make sure your care at MDA would not be compromised, esp. if you (let’s hope not!) had progression. The logistics working with hospitals for me are not at all a problem He/she should be quite willing since it’s MDA that is making this difficult. Nobody needs that when dealing with cancer! Best of luck to you.-
- December 8, 2019 at 12:27 am
Hi Michelle – thanks for your prompt and detailed response! Certainly your experience makes me feel more comfortable about the situation. I’m a Houston resident, so it’s still kind of frustrating because of silly billing red tape, but I agree it’s not a bad situation. Certainly could be worse, thanks again!
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- December 11, 2019 at 12:44 am
It may be time to lawyer up. Immunotherapy is covered under Coverage “b” in my Medicare plus supplement. At first, I was told Opdivo was not covered. It turns out it is, subject to any coverage “b” co-pay. My co-pay for all coverage “b” treatment is $4200 annually. I just finished my 4th Opdivo infusion and I pay nothing since the prior medical treatments for all coverage “b” treatments (scans, doctor visits, dermatology, primary care visits, etc. exceeded $4200. Starting January 1, I again will be responsible for co-pays only. Since my treatment is about 40,000 to 45,000 a month, all treatment after the first infusion are cost free. Your policy should pay all infusions after your co-pay. If your policy does not exclude Opdivo treatments it is likely covered. You may want to seek legal advice to review your policy coverages. It seems to me that they are viewing Opdivo as a prescription drug under Coverage “d”. It is part of Coverage “b”, not “d”.
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