Insurance Denying HRT Support Items - Help With Appeal?

[Blesum]

I am still having a hell of a time with Blue Shield and getting Armidex and HCG covered. Here's what the latest is:

I was given a script for the Armidex. The HCG Script was sent to a compounding company.

Rite Aid (local drug store) would not give me the Armidex saying it needed to be preauthorized by my Endo. The HCG was deined by Blue Shield at the compounding company.

My Endo contacted Rite Aid to do the pre-authorization, but then they said Blue Shield wouldn't approve it for male use.

My Endo sent in an appeal (for both, the Armidex and HCG) to Blue Shield. They declined.

My Endo re-appealed. They declined again saying they did not have enough justification for non-FDA approved off-label use. My Endo has given up, and at this point, it's up to me to take it up with Blue Shield. They won't let me start the appeal process until I get a certain letter from them (which still hasn't arrived despite them saying it was sent last week) that outlines how I can personally appeal.

I assume I will need to cite references and information that shows that these two substances are what I need (E2 at 62 [10-50] at last peak testosterone test and my nuts are smaller)

Other than Dr. John's paper, what other papers, research or sources should I cite assuming I'm supposed to do so? Where can I find information on the percentage of use of these products for HRT support - I heard that the number one use for one of these two products was actually for HRT support. Any other advice on the appeal process from a user's angle as opposed to a doctor's?

-Blesum

 

[SoMdHunter]

Blesum:

You may be in for a long and eventual loosing fight. My insurance won't even cover my Test C. Once I get to Dr John, I'm certain my insurance won't cover a bulk of whatever I get an Rx for. The reason I keep getting is that TRT or HRT is a quality of life issue, and not a health issue.

I wish I could direct you to studies that you could use which would change an insurance companies' mind. I doubt one exists though. Remember, insurance as in business to make a profit. They do this be offering reasonable services at reasonable rates. In their opinion (and that is the only one tha counts for them), your HRT meds fall outside the "reasonable" category.

 

[Blesum]

SoMdHunter,

If they denied the Testosterone Cyponiate, then I could see them not covering the support items. However, they seem to agree that the cyp is necessary and are covering it which makes me think that chances are, they can be made to cover the HCG and armidex. I would prefer not to resort to "research chemicals" for those two items but that's what it would come down to I guess.

A close friend who is in this field has indicated that if they continue to refuse to cover these two products and my side effects get more pronounced, I could easily have a lawsuit on my hands. This is absurd though and NOT what I want to do as I feel that would be determental to the whole HRT thing for myself and others. :rant:

-Blesum

 

[KSman]

HCG is cheap and maybe less than co-pays. At Sam's Club with the business membership, you can pick up 10,000iu of HCG (kit), non-recombinant) for $16.25. Research chems for AI will cost less than the co-pay as well. And test cyp there is $42 for 10ml of Watson's 200mg/ml. I pay all out of pocket.

 

[plymouth city]

Its a shame that health insurance is a money making venture

 

[SoMdHunter]

HCG is cheap and maybe less than co-pays. At Sam's Club with the business membership, you can pick up 10,000iu of HCG (kit), non-recombinant) for $16.25. Research chems for AI will cost less than the co-pay as well. And test cyp there is $42 for 10ml of Watson's 200mg/ml. I pay all out of pocket.

Now THAT is good news! Considering my Test C was $110 out of pocket (my insurance covered nothing), hopefully once Dr John gets done with me, I can afford all the meds!

 

[cpeil2]

SoMdHunter,

If they denied the Testosterone Cyponiate, then I could see them not covering the support items. However, they seem to agree that the cyp is necessary and are covering it which makes me think that chances are, they can be made to cover the HCG and armidex. I would prefer not to resort to "research chemicals" for those two items but that's what it would come down to I guess.

A close friend who is in this field has indicated that if they continue to refuse to cover these two products and my side effects get more pronounced, I could easily have a lawsuit on my hands. This is absurd though and NOT what I want to do as I feel that would be determental to the whole HRT thing for myself and others. :rant:

-Blesum

You probably have a ground for appealing the denial of coverage for the hCG. Carriers employ a variety of pretexts for not covering hCG -it all revolves around the fact that hCG is approved as a fertility drug. They either say that they don't cover fertility drugs, or that using a fertility drug to treat hypogonadism is an off-label use and they don't cover off-label uses. Either way, they are incorrect, because, if you read the package insert for hCG, one of the approved uses is as a treatment for hypogonadism. Some have gotten insurance to withdraw the denial using the above line of argument.


Arimidex may be tougher. I don't know what the approved uses of a-dex are, but I suspect that using it to control E2 levels in hypgogonadic males is an off-label use. Carriers often deny coverage for off-label use.

The A-dex isn't cheap, but you generally use tiny doses, maybe 2 or 3 times a week.


The hCG is pretty cheap - it is very easy to find 10K IU vials for around $45.00 or even less. And a 10K IU vial lasts a long time.

 

[BillfromNJ]

Blesum:

You may be in for a long and eventual loosing fight. My insurance won't even cover my Test C.

I lucked out I just went last night to Costco and paid $50.00 for my Test C. I'll know more on my Dr's AI choice tomorrow after reviewing latest blood work and hopefully that will be covered too

 

[plymouth city]

I lucked out I just went last night to Costco and paid $50.00 for my Test C. I'll know more on my Dr's AI choice tomorrow after reviewing latest blood work and hopefully that will be covered too

Business or regular membership?

 

[BillfromNJ]

Business or regular membership?

For RX you do not need a membership in NJ but I do have an expired family membership

 

[sidnee]

being self-employed, my health care provider just dropped me for HRT, imagine the risk they have with my "normal" testosterone levels?

 

[sidnee]

being self-employed, my health care provider just dropped me for HRT, imagine the risk they have with my "normal" testosterone levels?