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Insurance Coverage for Thyrogen

What to Do If Your Insurance Provider Won't Cover Thyrogen

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Updated September 18, 2013

If you have ever had to stop taking your synthetic thyroid hormone medication to prepare for thyroid cancer screening or treatment, you are well aware of how unpleasant the process can be for some patients. Going "hypo", or forcing the body into a hypothyroid state, can cause fatigue, mood swings, and other undesirable side effects that can temporarily affect your health and quality of life. This process had been the only available option for thyroid cancer patients until the FDA approved a drug in 2007 that alleviated the need to become hypothyroid prior to whole body scans and radioactive iodine treatment.

Thyrogen (thyrotropin alfa for injection), a synthetic form of thyroid stimulating hormone, is regarded as a miracle drug among thyroid cancer patients. With Thyrogen, you continue taking your daily thyroid hormone medication and do not experience the effects of being hypothyroid. Two small injections replace the weeks of fatigue, irritability, and headaches, making Thyrogen quite sought after by thyroid cancer patients. Unfortunately, many health insurance providers do not cover the cost of the drug and out of pocket cost is expensive.

It's not uncommon for insurance companies to deny authorization for Thyrogen. In fact, it has happened so frequently that Genzyme, Thyrogen's manufacturer, has created a program to assist you with acquiring the drug through your insurance company. If you are uninsured or your insurance will not cover it, there are several programs that can assist you in obtaining Thyrogen.

Insurance Coverage for Thyrogen

If you have health insurance and your doctor has recommended you receive Thyrogen injections, you should immediately contact ThyrogenONE, the free Thyrogen program designed to assist patients with obtaining insurance approval. The specialists at ThyrogenONE will verify your benefits under your policy and determine if the injections qualify under your health benefits plan or as a pharmacy benefit. ThyrogenONE will need your doctor to fax a form to them in order to verify your benefits. Your doctor's office may already have the necessary form in the office or you may download a PDF copy at the Thyrogen website. For more information about ThyrogenOne, please call 1-88-THYROGEN (1-888-497-6436).

Depending on your plan, Thyrogen may be covered as a medical or pharmacy benefit. Both may require you to meet a deductible or pay a co-pay. Some plans cover the entire cost, but coverage greatly varies based on your specific health plan. Once preliminary approval is received from your insurance provider, ThyrogenOne will send the information to a specialty pharmacy for final verification. The pharmacy will then send the Thyrogen injections directly to your doctor. If you do have a deductible or co-pay, the specialty pharmacy will contact you about payment before sending the medication to your doctor.

For Medicare Recipients: If you have Medicare, it is covered under Medicare Part B. No prior authorization is necessary. Your doctor's office will handle the processing of Medicare claims for Thyrogen. You may be responsible for 20 percent of the allowable reimbursement rate, either paid out of pocket or through a secondary plan.

For Medicaid Recipients: If you are covered under your state's Medicaid plan, Thyrogen may be covered. The doctor's office can verify coverage through the state's Medicaid office or ThyrogenOne. Benefits vary from state to state; some states require prior authorization which may delay you receiving Thyrogen injections.

What to Do If Your Insurance Denies Authorization for Thyrogen

If your insurance provider will not cover Thyrogen under your medical or pharmacy plan, you can appeal their decision. ThyrogenOne can help you with this process by gathering additional information and documentation from your doctor. You can certainly appeal the decision without the help of ThyrogenOne, but it will take a some effort.

Your first step in initiating the appeals process is to determine why authorization was denied. If you received a letter from your provider, it should state the reason. It is very important to save this letter as you may need it for future correspondence with the insurance company, your doctor, and patient assistance programs. Authorization if often denied because the insurance provider did not deem Thyrogen medically necessary. If this is the case, ask your doctor to write a letter notating why Thyrogen is medically necessary and other pertinent details to help support your appeal. Be sure to make copies of the letter, as you may need to resubmit them.

You may also choose to write a letter to submit with the doctor's letter to aid in your appeal. The Thyroid Cancer Survivors Association has a sample appeals letter for patients on their website that can help you draft a letter to your provider.

Information for Uninsured and Underinsured

If you do not have health insurance or your insurance company has denied authorization, you may be eligible to receive Thyrogen at no/low cost from the Thyrogen Patient Support Program. The program is offered through ThyrogenOne and applicants must meet certain criteria to be eligible. For more information about the Thyrogen Patient Support Program, please call 1-88-THYROGEN (1-888-497-6436).

There are several other programs that may be able to assist in paying for Thyrogen and possibly the co-pays associated with it. The Patient Access Network Foundation is a non-profit organization that provides financial assistance for many types of drugs, including Thyrogen. You can learn more about the organization by visiting their website at http://www.panfoundation.org/ or by calling 1-866-316-PANF (1-866-316-7263). More Patient Assistance Programs

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