... calling it a specialty drug and asking that it have extra costs. (Company as yet doesn't know how much the costs will be) Not only is this different than the insurance coverage that I had before but it is threatening for my well being. The FDA in countering my questions assured me that they aren't "Branding" any medications, any ideas how I might proceed? Have filed complaint with Insurance Commission in NYS. John
The company that makes Gammagard S/D has a program called Gardian that will help patients like us with insurance needs like this. You can go to their website www.mygardian.com or call them and they will try to help patients through insurance issues like this. There are insurance specialists who can try to help you through this process with your insurance company. The service is offered at no cost. Good luck with your S/D. My youngest is on the S/D low IgA and we feel very grateful there is medicine out there that works for our kids.
I had a similar problem with insurance. I am on Hizentra, not Gammagard, but they are all IgG. I hired an attorney and fought the company. It all came down to the fact that these IgG's are not medications, they are blood products that should fall under the blood/plasma provisions of your policy. They are made from human plasma of multiple donors for each vial. Your company is complaining because these IgG treatments are so expensive. IgG replacement therapy is a STANDARD OF CARE for Primary Immune Deficiency, or in my case, multiple myeloma. With most health insurance companies, it is considered a specialty drug simply because of the cost of it, and because it cannot be stocked in a normal neighborhood pharmacy. Hope this helps.
I don't know if you are still having a problem or not but if you are, I would suggest that you go to the following site and this will help you and your doctor appeal their decision: primaryimmune(dot)org/healthcare-professionals/health-insurance-denial-how-to-appeal. I would read everything on this site and get or download the books at this site. You need to get your doctor more involved especially in fighting the insurance company as they do not know anything about you. All they are concerned about is the cost and what deals they can make on specific drugs. They probably don't have anyone who really knows anything about IG therapy and the specific issues associated with the treatment.
Regarding your insurance company you have specific rights under Federal and State Law. You need to find out in writing, what is their appeal process. You must follow each of the steps or you may lose or delay your rights. You need to have them provide the diagnosis and treatment codes and their meanings sent to you. All if this should be provided to you for free. Typically the process is: Internal Appeal - you, your lawyer, or your doctor. Once you have completed the internal review process you can request an External Review - for you the NY State Insurance Commission. You cannot jump to the external review until the internal review is completed. If you meet the state law definition of URGENT and you have NOT received the service then you can request a Urgent Care Appeal. You will typically receive an answer within 72 hours. Hope this helps, good luck.
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