Temodar not covered as a treatment?

Hi there,

I'm new here and am so glad to have found this board.  My mother was diagnosed with a GBM 3 last month that is deemed inoperable. The recommended treatment is six weeks of radiation and 120 mg of Temodar daily.

Unfortunately, Blue Cross Blue Shield of Texas considers Temodar just a prescription instead of a medical procedure, like an intravenous chemotherapy.  Therefore they claim Temodar is subject to her $3,000/year cap on scripts.  It costs $9,000 for 42 days' worth!  We cannot come up with that amount every 42 days.  If this were an IV chemo it would be covered 100%.

So my question is, has anyone else run into this problem with getting Temodar?  If so did you have any success in appealing it?  I'm infuriated that the insurance would use this "loophole" to dodge paying for this critical treatment.  Any responses would be greatly appreciated.

Kindly,
Brian

Call the Commitment to Care program at Schering Plough... tomorrow! Or look it up online. You fill out the application and fax it in and they get right back to you... they are AMAZING. They called me back at 6 pm on a Friday night to tell me that Andy's application had been approved, that he would receive all his Temodar completely for free, and I burst into tears. It's SO stressful to wonder how you're going to pay for all of this. It can make you lose your cool for sure. 

My heart goes out to you. If you call the American Cancer society and/or look online for aid to cancer patients you'll find a lot. The CC program I mentioned above though was the lowest barrier, most compassionate and welcoming thing I just about ever experienced.

Love, hope and hugs,
Sarah

I would contest that with Blue Cross and Blue Shield. Basically what they are saying is that they don't cover treatments for a Brain Tumor. Something is wrong with that. Do not give up just because they initially deny it.  I would also talk with someone at M. D. Anderson. They have to deal with a number of patients that are covered by Blue Cross of Texas. They might have better insight on how to fight that.

Call the makers of Temodar they are very helpful with information and getting help with the cost of medicines.

Call the Texas senators and congress members.  They are in the middle of health care debates.

Larry

Thank you! Thank you!  We called Schering's Committment to Care program and you're right - they were amazing. They got back to us right away and we found out on Friday that they approved my mom and will be FedEx'ing her medication on Monday.  It is the only good news we've had since this entire ordeal began.

I never thought a big pharma company like that would respond so quickly to an individual patient's needs.  I'm so grateful to them and you.  Thank you for the wonderful advice.

Kindly,
Brian

We have BCBS of Florida, their most expensive policy, and had a similar problem. While we have no limits such as you mentioned on our drug coverage, because Temodar is an oral drug, they con't consider it chemo.. just a pharmaceutical drug.  Their 'excuse' is that it is administered by the patient not by a doctor or at a 'facility'.  In our case it is covered 100%, BUT... we have to pay for it first. The average person simply can't do that.. so the fact that it's 'covered 100%' is pretty useless.

Sheering-Plough (sp) gave us the first session, and but once it was discovered that it is 'covered 100%' they will no longer help, so thereafter the oncologists have no longer prescribed it.

It may sound harsh, though I doubt anyone here would feel so, but BCBS needs to step up to the plate and realize that chemo drugs increasingly now come in pill form. And expecting people to pay for chemo up front is NOT really coverage, because most people are unable to do this.

The poster who said that BCBS is just not covering brain cancer, has a point.

Our policy increases at least 15% each year and we are told to expect a 20% increase this year because I hit one of those age thresholds. Last year we increased our deductible so our premiums are 'only' approx. $15,000 per year. .. and for that they want you to pay for chemo up front!!

I think this problem with BCBS needs to be brought to a national attention level. Does anyone have a good idea on how to do that? I'm ready and able to do whatever is needed.