Re: Re: SynVisc - THANK YOU ALL

[Guest guest]

My husband had Synvisc paid for by regular Medicare (not Part D). I read

somewhere that some pharmacies don't understand Medicare reject codes -

that's they'll try to put drugs like Synvisc or oral chemotherapy through

under Part D - claim will be denied and patient charged, even though the

denial code is really saying that the drug charge needs to be submitted as a

medical expense under Part B.

Not on Medicare myself, but it seems that as usual the patient has look out

for themselves. By the way, two Synvisc series worked well for my husband

before he had to have a TKR. I had one series and it did absolutely nothing

(except make things worse for a few days).

Betsy (LTHR 6/08)

--------------------------------------------------

From: <leann40@...>

Sent: Monday, May 10, 2010 9:46 PM

<Joint Replacement >

Subject: Re: SynVisc - THANK YOU ALL

> Well she was told it would cost her $800.00 cash price for the injectable

> medication because her Medicare Part D provider stated that the synvisc

> one was not covered and then she asked if the other synvisc was maybe

> covered and I think even that was not covered. And so she called her

> provider and it was true.

> LEANN

>

>

>> > >

>> > > I appreciate everyone's response to my question about SynVisc. I

>> > > like the idea of trying SynVisc One, and will look into that. I have

>> > > scheduled my surgery for October, so I have some time to try the

>> > > injections, and maybe delay surgery.

>> > >

>> > > Cheryl

>> > >

>> >

>>

>

>

>

>

> ------------------------------------

>

>

[Guest guest]

I am far from an expert on Medicare reimbursements but my

understanding is that certain pharmaceuticals which are administered

in doctor's offices are covered by Medicare whereas those which are

purchased by a patient from a pharmacy are covered (if at all) under

the new prescription drug section.

This is creating some anomalous situations -- For example, there are

now chemotherapy drugs which can be taken by a patient at home but

they wouldn't be reimbursable in the same way as chemo is when done in

a medical facility.

Doctors profit from administering drugs like SynVisc and chemotherapy

because they are able to charge for the physician's services as well

as a mark up on the price they buy the drug for. Several years bag,

SynVisc was subject to an investigation because it was being charged

to Medicare at higher rates than it should have in terms of what the

physicians were paying for it.

I think it odd that your friend got a prescription for the drug which

was filled at a drugstore since drugs that are administered by a

doctor are generally not handled in that way. We don't fill

prescriptions for vaccines either as vaccines are also a " drug/

pharmaceutical agent " which is administered by a doctor -- or other

trained medical person.

On May 11, 2010, at 3:31 PM, leann40@... wrote:

> Betsy, (my first reply to you did not show up for some reason so

> here is another similar one)

>

> You are correct in that it is not something paid for by Part D. I

> talked to my friend again about this and she said her pharmacist had

> her call their chain's national center (an 800 number) which deals

> directly with Medicare and handles all the filling of special

> requests such as chemo etc. And they were the ones who told her that

> they would be happy to fill her RX and deliver the injectable

> Synvisc One medication to her docs office (delivery to the doc is a

> requirement they told her) but that all of their attempts to get

> Medicare to pay for it were rejected.

>

> Now I am wondering what is going on. I think she said she even asked

> about the mutiple injectable and was told " no dice " about Medicare

> paying for that as well.

>

> So now I don't like what I am hearing (reading) and I will now have

> to tell her about your husband getting his paid for by

> Medicare. Very Interesting. Thanks. And she was not working with a

> small chain pharmacy headquarters. It was a large well known one en

> who should know or should have known how to read " codes " or know

> when a payment is rejected.

>

> LEANN

>

>

> > >> > >

> > >> > > I appreciate everyone's response to my question about

> SynVisc. I

> > >> > > like the idea of trying SynVisc One, and will look into

> that. I have

> > >> > > scheduled my surgery for October, so I have some time to

> try the

> > >> > > injections, and maybe delay surgery.

> > >> > >

> > >> > > Cheryl

> > >> > >

> > >> >

> > >>

> > >

> > >

> > >

> > >

> > > ------------------------------------

> > >

> > >

[Guest guest]

There is something missing in this story. WIth all respect to your

friend, I often find that when people tell me things that run counter

to what normally occurs, there is often something missing in the story.

This is not a pharmaceutical that is handed out to the public because

it can only be utilized by a doctor. What if some kind of whack job

decided to inject the joint on their own?

I am not even sure that a doctor would inject something brought in by

a patient because they would not know the conditions in which it was

stored or acquired.

In the ordinary course, a doctor determines that a shot would be

medically necessary and does it in his office - billing Medicare for

the procedure which would include the substance injected.

On May 11, 2010, at 10:22 PM, leann40@... wrote:

> Could it be that Medicare now requires that doc's give their patient

> the option to decide what company they give their business to. I

> don't know anymore than that she ended up with her local pharmacy

> referring her to their corporate or national chemo division because

> they knew they could not get involved with or dispense that type or

> class of medication.

> LEANN

>

>

>

[Guest guest]

Not really since it doesn't explain why she didn't go to a doctor who

does it and stocks the medication. Normally a patient is not required

to provide a doctor with these kinds of medications that are stocked

in a doctor's office.

That's the part of the story I am not grasping. If a doctor suggests

the medical procedure, in my experience he or she always supplies the

pharmaceutical used. I've never been required to supply this kind of

" medicine " . I know people who have had various " shots " like this and

it seems to be standard operating procedure.

My guess is that the whole procedure is so outside of how Medicare

assumes " in-office " procedures are done, that it was just kicked back.

On May 12, 2010, at 2:15 PM, leann40@... wrote:

> Same respect back to you but I assumed that you read my post which

> stated that the friend was told by that national provider on the

> phone that the only way the medication could be handled once paid

> for by her was to have it shipped by them DIRECTLY to her the

> orthopedic docs office. Which is where she would have to go to get

> that Dr.

> to inject it into her knee.

>

> So does that make you more comfortable. But it still does not

> explain why hers was not going to get paid for by Medicare and

> another persons was.

>

> I DID find an article showing how what the doc answers on some

> questionaire and/or when asked about medical necessity can affect

> whether Medicare will pay or not. So her doc might not have been a

> very stong advocate if that was the case in her case.

>

> Take care, I hope this post makes you feel better about the confusion.

> LEANN

>

>

> >

> > > Could it be that Medicare now requires that doc's give their

> patient

> > > the option to decide what company they give their business to. I

> > > don't know anymore than that she ended up with her local pharmacy

> > > referring her to their corporate or national chemo division

> because

> > > they knew they could not get involved with or dispense that type

> or

> > > class of medication.

> > > LEANN

> > >

> > >

> > >

> >

> >

> >

> >

[Guest guest]

Forget Medicare -I'm not an expert.

I had a series of Synvisc injections in both knees - Fall 2008. Did no

good, BUT, my ortho gave me a script for the synvisc. Took it to my

pharmacy and it was rejected (I have CIGNA insurance). I called CIGNA and

they told me I needed to have the doc call in a script to their online /

specialty pharmacy and then it would be paid under medical benefits as

opposed to pharmacy. I had my ortho do that and they had the choice of

having it shipped to me or to them. I decided that given the 50 minute

drive to my ortho's office, I'd have it shipped to me. Each injection, I

carried up 2 sealed injections - no problem. Quite different form many

chemo / specialty drugs that need to be refrigerated, but Synvisc is just

pre-packaged in a box.

Anyway, that's my experience,

Betsy (LTHR 6/08)

--------------------------------------------------

From: <jujulabee@...>

Sent: Wednesday, May 12, 2010 5:25 PM

<Joint Replacement >

Subject: Re: Re: SynVisc - THANK YOU ALL

> Not really since it doesn't explain why she didn't go to a doctor who

> does it and stocks the medication. Normally a patient is not required

> to provide a doctor with these kinds of medications that are stocked

> in a doctor's office.

>

> That's the part of the story I am not grasping. If a doctor suggests

> the medical procedure, in my experience he or she always supplies the

> pharmaceutical used. I've never been required to supply this kind of

> " medicine " . I know people who have had various " shots " like this and

> it seems to be standard operating procedure.

>

> My guess is that the whole procedure is so outside of how Medicare

> assumes " in-office " procedures are done, that it was just kicked back.

>

> On May 12, 2010, at 2:15 PM, leann40@... wrote:

>

>> Same respect back to you but I assumed that you read my post which

>> stated that the friend was told by that national provider on the

>> phone that the only way the medication could be handled once paid

>> for by her was to have it shipped by them DIRECTLY to her the

>> orthopedic docs office. Which is where she would have to go to get

>> that Dr.

>> to inject it into her knee.

>>

>> So does that make you more comfortable. But it still does not

>> explain why hers was not going to get paid for by Medicare and

>> another persons was.

>>

>> I DID find an article showing how what the doc answers on some

>> questionaire and/or when asked about medical necessity can affect

>> whether Medicare will pay or not. So her doc might not have been a

>> very stong advocate if that was the case in her case.

>>

>> Take care, I hope this post makes you feel better about the confusion.

>> LEANN

>>

>>

>> >

>> > > Could it be that Medicare now requires that doc's give their

>> patient

>> > > the option to decide what company they give their business to. I

>> > > don't know anymore than that she ended up with her local pharmacy

>> > > referring her to their corporate or national chemo division

>> because

>> > > they knew they could not get involved with or dispense that type

>> or

>> > > class of medication.

>> > > LEANN

>> > >

>> > >

>> > >

>> >

>> >

>> >

>> >

[Guest guest]

I've had this done where the doctor supplied it and where I had to supply it.

When I had to supply it, it was ordered directly by the doctors office from the

insurers mail order pharmacy but it did not come from their stock. Two different

insurance compainies handled it differently.

The whole thing made no sense to me but our entire health insurance industry

makes no sense to me either.

Jeff

________________________________

From: " jujulabee@... " <jujulabee@...>

Joint Replacement

Sent: Wed, May 12, 2010 5:25:56 PM

Subject: Re: Re: SynVisc - THANK YOU ALL

Not really since it doesn't explain why she didn't go to a doctor who 

does it and stocks the medication. Normally a patient is not required 

to provide a doctor with these kinds of medications that are stocked 

in a doctor's office.

That's the part of the story I am not grasping. If a doctor suggests 

the medical procedure, in my experience he or she always supplies the 

pharmaceutical used. I've never been required to supply this kind of 

" medicine " . I know people who have had various " shots " like this and 

it seems to be standard operating procedure.

My guess is that the whole procedure is so outside of how Medicare 

assumes " in-office " procedures are done, that it was just kicked back.

On May 12, 2010, at 2:15 PM, leann40@... wrote:

> Same respect back to you but I assumed that you read my post which 

> stated that the friend was told by that national provider on the 

> phone that the only way the medication could be handled once paid 

> for by her was to have it shipped by them DIRECTLY to her the 

> orthopedic docs office. Which is where she would have to go to get 

> that Dr.

> to inject it into her knee.

>

> So does that make you more comfortable. But it still does not 

> explain why hers was not going to get paid for by Medicare and 

> another persons was.

>

> I DID find an article showing how what the doc answers on some 

> questionaire and/or when asked about medical necessity can affect 

> whether Medicare will pay or not. So her doc might not have been a 

> very stong advocate if that was the case in her case.

>

> Take care, I hope this post makes you feel better about the confusion.

> LEANN

>

>

> >

> > > Could it be that Medicare now requires that doc's give their 

> patient

> > > the option to decide what company they give their business to. I

> > > don't know anymore than that she ended up with her local pharmacy

> > > referring her to their corporate or national chemo division 

> because

> > > they knew they could not get involved with or dispense that type 

> or

> > > class of medication.

> > > LEANN

> > >

> > >

> > >

> >

> >

> >

> >

[Guest guest]

Not sure if this is the same thing, but when it was

suggested I get a shot to prevent shingles, the

doctor had to order it and the cost ($125) was

mine. Some items they do not keep on hand.

---- Original message ----

Date: Wed, 12 May 2010 14:25:56 -0700

From: jujulabee@...

Subject: Re: Re: SynVisc

- THANK YOU ALL

Joint Replacement

>Not really since it doesn't explain why she

didn't go to a doctor who

>does it and stocks the medication. Normally a

patient is not required

>to provide a doctor with these kinds of

medications that are stocked

>in a doctor's office.

>

>That's the part of the story I am not grasping.

If a doctor suggests

>the medical procedure, in my experience he or she

always supplies the

>pharmaceutical used. I've never been required to

supply this kind of

> " medicine " . I know people who have had various

" shots " like this and

>it seems to be standard operating procedure.

>

>My guess is that the whole procedure is so

outside of how Medicare

>assumes " in-office " procedures are done, that it

was just kicked back.

>

>On May 12, 2010, at 2:15 PM,

leann40@... wrote:

>

>> Same respect back to you but I assumed that you

read my post which

>> stated that the friend was told by that

national provider on the

>> phone that the only way the medication could be

handled once paid

>> for by her was to have it shipped by them

DIRECTLY to her the

>> orthopedic docs office. Which is where she

would have to go to get

>> that Dr.

>> to inject it into her knee.

>>

>> So does that make you more comfortable. But it

still does not

>> explain why hers was not going to get paid for

by Medicare and

>> another persons was.

>>

>> I DID find an article showing how what the doc

answers on some

>> questionaire and/or when asked about medical

necessity can affect

>> whether Medicare will pay or not. So her doc

might not have been a

>> very stong advocate if that was the case in her

case.

>>

>> Take care, I hope this post makes you feel

better about the confusion.

>> LEANN

>>

>>

>> >

>> > > Could it be that Medicare now requires that

doc's give their

>> patient

>> > > the option to decide what company they give

their business to. I

>> > > don't know anymore than that she ended up

with her local pharmacy

>> > > referring her to their corporate or

national chemo division

>> because

>> > > they knew they could not get involved with

or dispense that type

>> or

>> > > class of medication.

>> > > LEANN

>> > >

>> > >

>> > >

>> >

>> >

>> >

>> > [Non-text portions of this message have been

removed]

>> >

>>

>>

>>

>

>

>

>[Non-text portions of this message have been

removed]

>

>

>

>------------------------------------

>

>

[Guest guest]

I don't know about other doctors but the practice that I went to did not stock

Synvisc. You had to pay for it and it was shipped to their office. I then went

in to receive the injections. This a huge. Orthopedic practice in Nashville,TN

and this is a common practice in regards to Synvisc. My doctor said it is

because the med is so expensive.

Sent from my Verizon Wireless BlackBerry

Re: Re: SynVisc - THANK YOU ALL

Not really since it doesn't explain why she didn't go to a doctor who

does it and stocks the medication. Normally a patient is not required

to provide a doctor with these kinds of medications that are stocked

in a doctor's office.

That's the part of the story I am not grasping. If a doctor suggests

the medical procedure, in my experience he or she always supplies the

pharmaceutical used. I've never been required to supply this kind of

" medicine " . I know people who have had various " shots " like this and

it seems to be standard operating procedure.

My guess is that the whole procedure is so outside of how Medicare

assumes " in-office " procedures are done, that it was just kicked back.

On May 12, 2010, at 2:15 PM, leann40@... wrote:

> Same respect back to you but I assumed that you read my post which

> stated that the friend was told by that national provider on the

> phone that the only way the medication could be handled once paid

> for by her was to have it shipped by them DIRECTLY to her the

> orthopedic docs office. Which is where she would have to go to get

> that Dr.

> to inject it into her knee.

>

> So does that make you more comfortable. But it still does not

> explain why hers was not going to get paid for by Medicare and

> another persons was.

>

> I DID find an article showing how what the doc answers on some

> questionaire and/or when asked about medical necessity can affect

> whether Medicare will pay or not. So her doc might not have been a

> very stong advocate if that was the case in her case.

>

> Take care, I hope this post makes you feel better about the confusion.

> LEANN

>

>

> >

> > > Could it be that Medicare now requires that doc's give their

> patient

> > > the option to decide what company they give their business to. I

> > > don't know anymore than that she ended up with her local pharmacy

> > > referring her to their corporate or national chemo division

> because

> > > they knew they could not get involved with or dispense that type

> or

> > > class of medication.

> > > LEANN

> > >

> > >

> > >

> >

> >

> >

> >