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Tysabri and Insurance

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    Tysabri and Insurance

    My infusion center did not order the Tysabri through the correct specialty pharmacy so the insurance denied coverage, the Biogen one touch people told me not to worry about it when I inquired about it, but now they won't cover it either. In the end the hospital wants me to pay over $70,000. Surely this can't be right. Any suggestions?

    #2
    Originally posted by schmangi View Post
    My infusion center did not order the Tysabri through the correct specialty pharmacy so the insurance denied coverage, the Biogen one touch people told me not to worry about it when I inquired about it, but now they won't cover it either. In the end the hospital wants me to pay over $70,000. Surely this can't be right. Any suggestions?
    Fight it! If it was the hospital's fault for ordering through the wrong specialty company, and your insurance company had already pre authorized payment for it, it was entirely THEIR fault, so THEY are the ones who should eat the cost. Not Biogen, or you.

    My infusion center/ hospital had to eat the cost for 3 infusions when they billed it wrong to my insurance company, which had changed how it was supposed to be billed (thru my speciality pharmacy, not the medical portion) a few years ago. Normally, because it is an infusion, it is billed through the medical portion of insurance policicies. Kept being told by insurance company it was authorized, so all was a go, and kept getting green light for my infusions. But then insurance would deny payment. (Told mine was the only one large MS clinic had ever had like it.) It's all about cost, and this has been their cheapest way to negotiate that cost. (Unbelievable the price they currently have it negotiated down to.).

    It took a lot of phone calls by my MS clinic (who eventually did ask for Biogen's help, they also had no idea what was going on), the infusion center, myself, and even my husband's HR department to finally figure it out.It was a huge headache for everyone involved. Don't know why insurance company reps spoke with seemed clueless. Biogen offered my medication at no cost, before an upcoming infusion. In the end, I was only held responsible for my portion of the infusion center costs. (Still seems to me my insurance company was partly responsible for not providing the correct billing information, since they are the ones who changed it, in the beginning of the mess).

    My advice to you is not to pay it, and contact your insurance company to make certain it was authorized. (Mine always gave it a number). Make a stink about it to the infusion center/ hospital and billing department if you have to. My bet is they will be the ones eating the cost for their mistake. If they continue to bill you and threaten your bill will be forwarded to a collection agency, contact a lawyer. Also make sure you are enrolled in the patient assistance programs to help cover co-pays/ deductibles. https://www.tysabri.com/en_us/home/j...l-support.html

    Good luck, and please keep us updated!
    Last edited by Kimba22; 03-30-2017, 01:05 AM.
    Kimba

    “When you change the way you look at things, the things you look at change.” ― Max Planck

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      #3
      Thanks for the good advice. It's so frustrating. My hospital says that they've never heard of a specialty pharmacy, what? I find it hard to believe I was their first patient on Tysabri.

      I haven't been on Tysabri since December because my new insurance is also playing games before I even get an infusion. I really don't need this hassle on top of dealing with this disease!

      Thanks again, I'll keep you posted.

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        #4
        That's nuts! I've been to three different infusion centers, and none of them went through a specialty pharmacy. A specialty pharmacy is for prescriptions! My centers just have the Tysabri in stock because it is a medical procedure. It could be your infusion center has never dealt with Tysabri before. I agree! Fight! $70,000! My entire infusion is only $7500, and of that, the Tysabri is probably $4500?

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          #5
          Going off Ty because no co-pay assistance anymore.

          My Tysabri infusion was to be next week. Is anyone else having problems getting co-pay assistance? I am. I like Tysabri. It is working. However the co-pay assistance rug has been pulled out from under me. I blame Biogen.

          I was on assistance from grant. Money ran out. I knew this was going to happened months ago. So did my infusions nurse so we were proactive and applied for free drug program that would start this month. Biogen sent me letter that I qualified for the free drug program until my grant funding had been processed and paid. Then I would reapply. . Yesterday they called and told me that they were not doing briding the funding gap anymore but gave me a connection to another funding source. I qualified. BUT - I cannot get that funding until the other funding has been "exhausted". Problem is that even though I do not have enough m funding for more infusions, records show that I have $3,700 because the claims are still in the pipeline and the money has not been paid. The reason is that it takes about 60 days for claims to be processed by Medicare and another 30-60 days for the copay assistance to go through. Then I have $300 left, which doesn't cover but +/- 1/3 of my co-pay. I can not afford the $800 difference.

          My infusion nurse is battling with Biogen to get my Tysabri for free until I can get the funding issues taken care of. I decide to call too. The Biogen assistance program representative looked into my situation and told me the only options I had other than to pay out of pocket was to call Medicare and ask them to ask them to expedite the claims and to keep calling. I told him I wasn't going to do that because it would just take away Medicare's time, my time and why would they bump me above others? Medicare is already understaffed and underfunded - downsizing by attrition. I'm not blaming Medicare or asking favors. I have traditional Medicare and monitor EOBs. If billed correctly it takes 30 days to process and another 30 -45 to pay. I've never had a claim unpaid for over 90 days unless there was a coding error. So, no money, no medicine. ObamaCare itself doesn't have anything to do with this. Perhaps Biogent playing politics does. Some people may cry "fowl" but the only impact that law had on me personally was a smaller donut hole. Lots of problems with the ACA but traditional medicare is not a part. The advantage plans have been hiking premiums every year and making preauthorizations difficult. That's why I went back to just Medicare. I have 101 problems but Obamacare ain't one. Being told "we want to make sure you have your medication so here it is". Then less than a week before my infusion I'm told "nope" - that's a big problem!

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