Insurance

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beach sunrise
Posts: 1041
Joined: Thu Mar 05, 2020 7:14 pm

Insurance

Postby beach sunrise » Thu Mar 21, 2024 8:48 pm

OK, I got a letter from BCBS stating they put my capcetibine under review and it will be under review every year provided it be rx'd with in network provider. So, are they planning to exclude certain doctors outside of SOC? My onc is intergrative. I can see trouble coming with several scenarios for this happening.
Anyone else with BCBS get a letter about oral chemo?
8/19 RC CEA 82.6 T3N0M0
5FU/rad 6 wk
IVC 75g 1 1/2 wks before surgery. Continue 2x a week
Surg 1/20 -margins T4bN1a IIIC G2 MSI- 1/20 LN+ LVI+ PNI-
pre cea 24 post 5.9
FOLFOX
7 rds 6-10 CEA 11.4 No more
CEA
7/20 11.1 8.8
8/20 7.8
9/20 8.8, 9, 8.6
10/20 8.1
11/20 8s
12/20 8s-9s
ADAPT++++ chrono
CEA
10/23/22 26.x
12/23/22 22.x
2023
1/5 17.1
1/20 15.9
3/30 14.9
6/12 13.3
8/1 2.1
Nodule RML SUV 1.3 5mm
Rolles 3 of 4 lung nodules cancer
KRAS
Chem-sens test failed Not enough ca cells to test

rp1954
Posts: 1855
Joined: Mon Jun 13, 2011 1:13 am

Re: Insurance

Postby rp1954 » Sat Mar 23, 2024 2:26 pm

beach sunrise wrote:OK, I got a letter from BCBS stating they put my capcetibine under review and it will be under review every year provided it be rx'd with in network provider. So, are they planning to exclude certain doctors outside of SOC? My onc is intergrative. I can see trouble coming with several scenarios for this happening.
Anyone else with BCBS get a letter about oral chemo?


Ah, the all unknowing insurance review letter.
In fairness, insurance reviews have the potential to suggest other useful possibilities.
However many seasoned patients have other views and experiences, where suggest becomes compel, and potentially useful becomes uncomfortable, useless, and/or dangerous.

With the letter's phrase, "it will be under review every year provided it be rx'd with in network provider", one wonders what their thinking or angle is.
Maybe they are weirded out by the lack of Avastin, -iri, -oxi with all that xeloda.
Maybe they consider long term xeloda of "unproven benefit???" despite very heterogenous patient situations and response histories.
Is it part of a bland, broader attack on out of network doctors' costs.

First since it is "every year", the "under review" (or some policy change?) addresses your situation as a mCRC patient, since stage 3 patients are done in 6 months with straight Xeloda cycles. So that eliminates a large component of xeloda users and potential compatriots, the stage 2 and 3 initial tx patients.

Second, is that I would suspect that BCBS is interfering in things it has no real clue of the spectrum of xeloda utility, with some common failure modes in oncology with underpowered xeloda regimens vs better "experimental" regimes.

A serious problem is how frank a discussion is possible with in-network doctors "owned" by the insurance companies and whether consults with the uninformed or even hostiles can prejudice or complicate your insurance once they understand your nonSOC therapeutic situation beyond the most basic xeloda "SoC" usages.

On your side should be employers that appreciate their employee (familys) lives, or employees that take extraordinary steps to achieve an actual cure and contain costs. Certainly accountants and shareholders should protest against SoC agents (doctors or insurance administrators) that would effectively switch a month's $xxx gasoline bill for 1-2 first class air tickets around the world, every month.
watchful, active researcher and caregiver for stage IVb/c CC. surgeries 4/10 sigmoid etc & 5/11 para-aortic LN cluster; 8 yrs immuno-Chemo for mCRC; now no chemo
most of 2010 Life Extension recommendations and possibilities + more, some (much) higher, peaking ~2011-12, taper chemo to almost nothing mid 2018, IV C-->2021. Now supplements

User avatar
beach sunrise
Posts: 1041
Joined: Thu Mar 05, 2020 7:14 pm

Re: Insurance

Postby beach sunrise » Sat Mar 23, 2024 7:09 pm

Thank you for your thoughts on this, Rp. Much appreciated. I see sinister things fixing to happen within the next year mostly likely due to increasing profit over patient scenarios. Hands swiping hands.
BCBS also sent thr letter to my onc so our appt will be interesting.
8/19 RC CEA 82.6 T3N0M0
5FU/rad 6 wk
IVC 75g 1 1/2 wks before surgery. Continue 2x a week
Surg 1/20 -margins T4bN1a IIIC G2 MSI- 1/20 LN+ LVI+ PNI-
pre cea 24 post 5.9
FOLFOX
7 rds 6-10 CEA 11.4 No more
CEA
7/20 11.1 8.8
8/20 7.8
9/20 8.8, 9, 8.6
10/20 8.1
11/20 8s
12/20 8s-9s
ADAPT++++ chrono
CEA
10/23/22 26.x
12/23/22 22.x
2023
1/5 17.1
1/20 15.9
3/30 14.9
6/12 13.3
8/1 2.1
Nodule RML SUV 1.3 5mm
Rolles 3 of 4 lung nodules cancer
KRAS
Chem-sens test failed Not enough ca cells to test

claudine
Posts: 809
Joined: Tue Mar 12, 2019 2:41 pm
Location: Montana

Re: Insurance

Postby claudine » Mon Mar 25, 2024 9:43 am

DH also has BCBS, and is also taking Xeloda on its own, but we haven’t received anything (yet). Different BCBS I guess? Since they wouldn’t cover Lonsurf, hopefully they’ll keep his Xeloda coverage. It seems to be working (last week’s scan showed lymph node decreased in size and everything else stable).
As someone who grew up in a country with socialized medicine, the US healthcare system seems so incredibly complicated to me! Good luck navigating it, Beach xxxxx
Wife of Dx 04/18 (51 yo). MSS, KRAS G12A, no primary

Tumors: L4 04/18; left adrenal gland & small lung nodules 03/19
rectum 02/22 (pT3 pN0 stage 2A); L3 09/22

Surgeries: intestinal resect. 05/18 (no cancer - Crohn's); adrenalectomy 02/20
L3-L4-L5 fusion and corpectomy 05/20; LAR 04/22; ileo reversal 09/22
L2-L3 fusion and corpectomy 09/22

Treatments: EBRT 04/18; SBRT 02/19; Failed adjuvant Xelox ; Folfiri/Avastin 03/19 - 01/20
adjuvant chemorad (Xeloda) 06/22; SBRT 11/22; Xeloda/Avastin since 01/24

User avatar
beach sunrise
Posts: 1041
Joined: Thu Mar 05, 2020 7:14 pm

Re: Insurance

Postby beach sunrise » Mon Mar 25, 2024 1:26 pm

Claudine, thank you for your reply! Much appreciated.
Please let me know if you get a letter.
Our health care system is clown world absurd!!!
8/19 RC CEA 82.6 T3N0M0
5FU/rad 6 wk
IVC 75g 1 1/2 wks before surgery. Continue 2x a week
Surg 1/20 -margins T4bN1a IIIC G2 MSI- 1/20 LN+ LVI+ PNI-
pre cea 24 post 5.9
FOLFOX
7 rds 6-10 CEA 11.4 No more
CEA
7/20 11.1 8.8
8/20 7.8
9/20 8.8, 9, 8.6
10/20 8.1
11/20 8s
12/20 8s-9s
ADAPT++++ chrono
CEA
10/23/22 26.x
12/23/22 22.x
2023
1/5 17.1
1/20 15.9
3/30 14.9
6/12 13.3
8/1 2.1
Nodule RML SUV 1.3 5mm
Rolles 3 of 4 lung nodules cancer
KRAS
Chem-sens test failed Not enough ca cells to test


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