Re: Clarifying the insurance process for Xolair

[Guest guest]

~STEVE ZIMMERMAN, CPM, CVOM~

________________________________

From: [mailto: ]

On Behalf Of

Sent: Tuesday, May 30, 2006 6:16 PM

Subject: [ ] Clarifying the insurance process for Xolair

Hello - I hope everyone had a good Memorial Day weekend!

I am preparing to talk to my doctor about trying Xolair for my throat

problems. First I need to do a little more homework though! I would

like to be as knowledgeable as possible before even approaching my

doctor about it. Below I have summarized my understanding about how

insurance coverage usually works for Xolair. Please let me know if

this sounds right!

This is my understanding:

In order to determine which insurance company (medical or

prescription) should provide coverage, I need to know how my doctor's

office administers Xolair.

Scenario 1: If the doctor's office orders and supplies the Xolair

themselves, then my medical insurance will most likely be responsible

for coverage. [sCZ] Yes, this is how it works for me

Scenario 2: If the doctor prefers to order Xolair through my

specialty pharmacy and have it shipped to them, then my pharmacy

insurance will cover this portion, but the administration of the shot

will be covered by medical.[sCZ] In my case, the doctors office orders

the xolair which is covered

by the insurance (80%) and I am responsible for 20% . I am also

expected to pay

for the administration of the shot which is about $50.00 or so each time

I come in.

Two more questions: Since I would be using Xolair off-label, it is

probable that my insurance will deny coverage.

[sCZ] In my opinion, this is a possibility.

In this situation, do you think it's best for the doctor to explain my

medical situation

when first applying for approval, or is it best to submit this during

the appeals process?

[sCZ] I would always have your doctor deal with the approval process

first. It will save you a lot of time and effort in the

long run.

Also, if I am denied coverage, does anyone know

if I would typically still receive the insurance's discounted pricing

on the Xolair?[sCZ] You might be able to do this if you can provide a

good reason for needing the discount.

Thanks so much for your help!

, 32, Louisville

[Guest guest]

, if you get to the point that your insurance will not cover

the off label use (and they may be willing to try if they are paying

out the wazoo for you to go to the ER and take a lot of other meds),

get your doc to contact the Genentech rep directly to try to

advocate for you to get a discount. Genentech may want some

feedback on the success of your off label use and be willing to cut

you a deal. You never know. They are a very good company - I've

heard a lot of good things about them from several different

quarters, both physician and consumer.

Addy

--- In , " Steve Zimmerman " <steve@...>

wrote:

>

>

>

> ~STEVE ZIMMERMAN, CPM, CVOM~

>

>

> ________________________________

>

> From:

[mailto: ]

> On Behalf Of

> Sent: Tuesday, May 30, 2006 6:16 PM

>

> Subject: [ ] Clarifying the insurance process for Xolair

>

>

> Hello - I hope everyone had a good Memorial Day weekend!

>

> I am preparing to talk to my doctor about trying Xolair for my

throat

> problems. First I need to do a little more homework though! I

would

> like to be as knowledgeable as possible before even approaching my

> doctor about it. Below I have summarized my understanding about

how

> insurance coverage usually works for Xolair. Please let me know

if

> this sounds right!

>

> This is my understanding:

> In order to determine which insurance company (medical or

> prescription) should provide coverage, I need to know how my

doctor's

> office administers Xolair.

>

> Scenario 1: If the doctor's office orders and supplies the Xolair

> themselves, then my medical insurance will most likely be

responsible

> for coverage. [sCZ] Yes, this is how it works for me

>

> Scenario 2: If the doctor prefers to order Xolair through my

> specialty pharmacy and have it shipped to them, then my pharmacy

> insurance will cover this portion, but the administration of the

shot

> will be covered by medical.[sCZ] In my case, the doctors office

orders

> the xolair which is covered

> by the insurance (80%) and I am responsible for 20% . I am also

> expected to pay

> for the administration of the shot which is about $50.00 or so

each time

> I come in.

>

> Two more questions: Since I would be using Xolair off-label, it

is

> probable that my insurance will deny coverage.

> [sCZ] In my opinion, this is a possibility.

>

> In this situation, do you think it's best for the doctor to

explain my

> medical situation

> when first applying for approval, or is it best to submit this

during

> the appeals process?

> [sCZ] I would always have your doctor deal with the approval

process

> first. It will save you a lot of time and effort in the

> long run.

>

> Also, if I am denied coverage, does anyone know

> if I would typically still receive the insurance's discounted

pricing

> on the Xolair?[sCZ] You might be able to do this if you can

provide a

> good reason for needing the discount.

>

> Thanks so much for your help!

> , 32, Louisville

>

>

>

>

>

>

>

>

>

>

[Guest guest]

Addy, contacting Genentech is a very good idea. Xolair has helped much more

than my asthma so I suspect the company would be especially interested in

information concerning off-lable use. It seems the treatment for allergies will

be heading in an entirely different direction in the future, thanks to Xolair.

pyle456 <coachmac@...> wrote: , if you get to the point that

your insurance will not cover

the off label use (and they may be willing to try if they are paying

out the wazoo for you to go to the ER and take a lot of other meds),

get your doc to contact the Genentech rep directly to try to

advocate for you to get a discount. Genentech may want some

feedback on the success of your off label use and be willing to cut

you a deal. You never know. They are a very good company - I've

heard a lot of good things about them from several different

quarters, both physician and consumer.

Addy

--- In , " Steve Zimmerman " <steve@...>

wrote:

>

>

>

> ~STEVE ZIMMERMAN, CPM, CVOM~

>

>

> ________________________________

>

> From:

[mailto: ]

> On Behalf Of

> Sent: Tuesday, May 30, 2006 6:16 PM

>

> Subject: [ ] Clarifying the insurance process for Xolair

>

>

> Hello - I hope everyone had a good Memorial Day weekend!

>

> I am preparing to talk to my doctor about trying Xolair for my

throat

> problems. First I need to do a little more homework though! I

would

> like to be as knowledgeable as possible before even approaching my

> doctor about it. Below I have summarized my understanding about

how

> insurance coverage usually works for Xolair. Please let me know

if

> this sounds right!

>

> This is my understanding:

> In order to determine which insurance company (medical or

> prescription) should provide coverage, I need to know how my

doctor's

> office administers Xolair.

>

> Scenario 1: If the doctor's office orders and supplies the Xolair

> themselves, then my medical insurance will most likely be

responsible

> for coverage. [sCZ] Yes, this is how it works for me

>

> Scenario 2: If the doctor prefers to order Xolair through my

> specialty pharmacy and have it shipped to them, then my pharmacy

> insurance will cover this portion, but the administration of the

shot

> will be covered by medical.[sCZ] In my case, the doctors office

orders

> the xolair which is covered

> by the insurance (80%) and I am responsible for 20% . I am also

> expected to pay

> for the administration of the shot which is about $50.00 or so

each time

> I come in.

>

> Two more questions: Since I would be using Xolair off-label, it

is

> probable that my insurance will deny coverage.

> [sCZ] In my opinion, this is a possibility.

>

> In this situation, do you think it's best for the doctor to

explain my

> medical situation

> when first applying for approval, or is it best to submit this

during

> the appeals process?

> [sCZ] I would always have your doctor deal with the approval

process

> first. It will save you a lot of time and effort in the

> long run.

>

> Also, if I am denied coverage, does anyone know

> if I would typically still receive the insurance's discounted

pricing

> on the Xolair?[sCZ] You might be able to do this if you can

provide a

> good reason for needing the discount.

>

> Thanks so much for your help!

> , 32, Louisville

>

>

>

>

>

>

>

>

>

>

[Guest guest]

Hi :

I'm getting back to you about the low Ige counts. I went on the Xolair web

site, and it states low titiers of antibodies were detected in app. 1/1723

(0.2%) ofn patient treated with Xolair. It states that caomparison of the

indience of antibodies to Xolair with the incidence of antibodies to other

products may be misleading.

Check the web site out.

Kathy

McLaughlin <gmclaughlin1000@...> wrote:

Addy, contacting Genentech is a very good idea. Xolair has helped much more

than my asthma so I suspect the company would be especially interested in

information concerning off-lable use. It seems the treatment for allergies will

be heading in an entirely different direction in the future, thanks to Xolair.

pyle456 <coachmac@...> wrote: , if you get to the point that

your insurance will not cover

the off label use (and they may be willing to try if they are paying

out the wazoo for you to go to the ER and take a lot of other meds),

get your doc to contact the Genentech rep directly to try to

advocate for you to get a discount. Genentech may want some

feedback on the success of your off label use and be willing to cut

you a deal. You never know. They are a very good company - I've

heard a lot of good things about them from several different

quarters, both physician and consumer.

Addy

--- In , " Steve Zimmerman " <steve@...>

wrote:

>

>

>

> ~STEVE ZIMMERMAN, CPM, CVOM~

>

>

> ________________________________

>

> From:

[mailto: ]

> On Behalf Of

> Sent: Tuesday, May 30, 2006 6:16 PM

>

> Subject: [ ] Clarifying the insurance process for Xolair

>

>

> Hello - I hope everyone had a good Memorial Day weekend!

>

> I am preparing to talk to my doctor about trying Xolair for my

throat

> problems. First I need to do a little more homework though! I

would

> like to be as knowledgeable as possible before even approaching my

> doctor about it. Below I have summarized my understanding about

how

> insurance coverage usually works for Xolair. Please let me know

if

> this sounds right!

>

> This is my understanding:

> In order to determine which insurance company (medical or

> prescription) should provide coverage, I need to know how my

doctor's

> office administers Xolair.

>

> Scenario 1: If the doctor's office orders and supplies the Xolair

> themselves, then my medical insurance will most likely be

responsible

> for coverage. [sCZ] Yes, this is how it works for me

>

> Scenario 2: If the doctor prefers to order Xolair through my

> specialty pharmacy and have it shipped to them, then my pharmacy

> insurance will cover this portion, but the administration of the

shot

> will be covered by medical.[sCZ] In my case, the doctors office

orders

> the xolair which is covered

> by the insurance (80%) and I am responsible for 20% . I am also

> expected to pay

> for the administration of the shot which is about $50.00 or so

each time

> I come in.

>

> Two more questions: Since I would be using Xolair off-label, it

is

> probable that my insurance will deny coverage.

> [sCZ] In my opinion, this is a possibility.

>

> In this situation, do you think it's best for the doctor to

explain my

> medical situation

> when first applying for approval, or is it best to submit this

during

> the appeals process?

> [sCZ] I would always have your doctor deal with the approval

process

> first. It will save you a lot of time and effort in the

> long run.

>

> Also, if I am denied coverage, does anyone know

> if I would typically still receive the insurance's discounted

pricing

> on the Xolair?[sCZ] You might be able to do this if you can

provide a

> good reason for needing the discount.

>

> Thanks so much for your help!

> , 32, Louisville

>

>

>

>

>

>

>

>

>

>

[Guest guest]

Steve – thanks for your comments about how your insurance processes

your Xolair treatment. I really appreciate it!

Addy – thank for the suggestion to have my doctor contact Genentech

about off-label use. I actually contacted Genentech's Access to Care

Foundation a few months ago. The rep I talked to said that they do not

offer prescription assistance for off-label use of Xolair at this time.

Oh well...

I haven't even talked to my doctor yet...he may completely poo-poo the

idea. I'll let you all know when I get the nerve up to talk to him!

Thanks again!

, 32, Louisville