Radicava patients - any advice on going through another Prior Authorization to extend it again?

[DW96]

I had the Prior Authorization done last year, which took forever, finally was approved last year for 6 months from my insurance company. Now I have to have the neuro do it again and waiting back to hear. I'm going to probably have to cancel all my infusions for next week as it's only authorized through tomorrow. The neuro nurse just emailed back tonight and said she see in my file that the neuro has to do a peer to peer meeting for the Prior Authorization and she will check with the doctor and find out when a good time to do that is. I Googled it and sounds like she has to talk to a physician of the payer (insurance company) to discuss why I need the treatment. I don't know if the neuro had to do that the first time or if this is a hurdle they have to get through to extend it.
Anyone been through this?

 

[Nikki J]

Peer to peers aren’t unusual Certainly sometimes the insurance asks for one to start radicava. Supposedly they arefor situations where they need more information to decide. Sometimes it feels like it is just an extra hoop. They happen a lot and most times the patient doesn’t even know. The actual conversation isn’t usually long but it does need a time where the doctor is available. If the insurance doctor approves they can usually do the approval code on the spot

 

[DW96]

Ok thanks, I will warn the hospital tomorrow that I may not be in next week unless I hear that I have the approval. Just worried my insurance is probably not wanting to because the hospital charges 8K every day I go in for infusion. Ridiculous

 

[lisa g]

I've been getting Radicava infusions for 2 years and have never had to do a peer to peer. The neurologist wrote the script for a year and then renewed it. And yes the cost to do it at the infusion center is ridiculous. I'm charged $7900.00 per infusion. Hopefully the oral Radicava will be approved soon.

 

[DW96]

I am hoping the oral will be available soon too! would be so much easier than infusing it! And I actually feel bad for insurance companies getting charged this per day!

 

[sassy]

My husband goes to Mass General and they submit the request to our insurance company. Fortunately for us, this has been a seamless process.

 

[rnewton60]

I have been on it for two years and I see my insurance company is paying about $400 out of the $15,000 charge. I would be surprised if anyone's insurance is paying 100% of any Radakava bill.

 

[lisa g]

Newton60, I too have been on Radicava for 2 years, between Medicare and my private secondary insurance I haven't paid one penny. I go to an infusion center. I believe when I started I was told if I received them at home I would be charged $200.00 out of pocket.

 

[Pauliguy]

I am lucky, I am infusing at home and there is no cost through Kaiser. I am charged $20 for a doctor’s visit, but nothing to go to the infusion center for them to access my port. It seems that since they are both the insurance company and health care provider, I didn’t have to convince them to provide Radicava. The only real hassle is getting my port accessed, twice during the 10-day period. They let me pop out the needle myself, saving me a trip. I still have one good hand; I don’t know what will happen if and when the other hand fails, and I can no longer infuse by myself. I don’t know if they will provide homecare, or I will need to train someone.

 

[DW96]

Pauliguy - they let you infuse yourself, or they send someone to your home every day?
rnewton60 - I am lucky once I meet my 3000 deductible for the year (which one infusion meets that!) my insurance pays 100% of my doctors, surgery, infusions of Radicava
And my insurance finally approved it for another 6 months. I had 2 skip 2 infusions though because they didn't have the prior auth ready to until the afternoon of the 2nd day I missed.