Experience getting Foundation One to pay for Molecular Profiling

Has any one had successful approval by Foundation One for molecular profiling? My insurance company (Anthem BC/BS) has denied approval as it was considered investigational despite usage being shown by Foundation One as medically necessary.

Currently I've been on Olaparib since October 2015 for treatment of a CDK12 mutation that is being treated that is a comparable BRCA2 mutation.

If one anyone has experience with their insurance company or with Medicare it would be appreciated.

Dominic Marrese

Typed or transcribed from my iPhone

8 Replies

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  • Dominic, Frank was approved by Foundation One for 100% coverage of all costs of testing. We were given some financial forms to fill out by Frank's oncologist which he submitted for us along with other paperwork. We were sent an approval letter directly from Foundation One before we scheduled a new bone biopsy. His oncologist wanted new biopsy rather than using 2 year old sample. Foundation One billed our insurance company, was denied, will appeal once and then cover the costs. Just received the EOB from Blue Shield...Foundation One billed BS $5800.00. Call if you have any questions...208.772.1845.

    Lisa

  • Thanks Lisa. I may be in touch. I certainly don't want to shell out $5800. Given I benefitted by Olaparib I should receive coverage.

    Thank you !

  • Dominic, Like all the other Pharms (although it isn't a pharma) Foundation does have financial assist programs and should also be willing to help get insurance reimbursement. Their program is called FoundationACCESS . Go to their web page and see if there is a way to get them to assist you with your insurance company.

    Joel

  • I am familiar with it. I've been in touch with them over last 6 months so I need to figure out what's going on. Not sure my doc provided enough details.

    I was also originally denied Olaparib as well and had to appeal to my wife's company to get approval for that so it's just part of the process to shut my down my meds.

    Nonetheless thanks for sharing.

    Dominic

  • I should have assumed that you had already covered that possibility. I am pulling for you. - Joel

  • Thanks Joel. It's very frustrating. In my opinion, some insurance companies want to do whatever possible to complicate outcome. Hopefully it will eventually work out.

  • My husband was denied a billing for $5800, but there must be some sort of mix-up because what we wanted was the Heme test ($7000+ according to the website), to find out what the new tumor is after Extandi made all the other ones disappear. It is sandwiched between aorta and L1 vertebrae and no dr. wants to biopsy or remove it. The only biopsy material is 7 yrs old and mostly the wrong stuff.

  • Hi Dominic,

    I had a Foundation One Molecular pathology procedure done on 12/6/15.

    I did not have to pay for it based on what my Medicare Summary Notice

    statement showed which was:

    Cost - $5,800.00

    Medicare approved amount – 0

    Amount Medicare Paid – 0

    Maximum you may be billed - 0

    However, there were 2 footnotes on this notice.

    Footnote A – The information provided does not support the need for this service.

    Footnote B – You didn’t know this service was not provided so you don’t have to pay. Future services of this type won’t be paid.

    I never heard of such a thing, but naturally I didn’t complain.

    It’s true I did not know that it would not be paid. My doctor just said he would have the study done.

    Unfortunately, he is on vacation and won’t be back until 6/1 when I will meet with him.

    I will ask him how this all came about and get back to you.

    Hope you are feeling better Dominic.

    Chuck Preller

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