My husband will need Lupron injections monthly x4. Two before starting radiation, and 2 during radiation treatment. The insurance, Medicare Advantage PPO, denied it. Anyone successfully appealed the denial? Any suggestions from the group? I checked and Medicare part D covers Lupron for the treatment of Prostate Cancer. The Medicare Advantage plans must provide the "same or better" coverage.
The Inquisitive One
PPO? Every Advantage plan I’ve heard about requires all your doctors to be in their network
Yes. According to Medicare, "A Preferred Provider Organization (PPO) Plan is a Medicare Advantage Plan that has a network of doctors, specialists, hospitals, and other health care providers you can use."
However, " If you’re planning to join a PPO and you want Medicare drug coverage (Part D), you must join a PPO Plan that offers Medicare drug coverage."
See Page 13 in here: medicare.gov/Pubs/pdf/12026...
I've known several patients get the doctor-recommended treatment on appeal. Your doctor can request a "peer-to-peer" review. Lupron is covered under Part B of Medicare because it is injected in the doctor's office.
Blue Shield was allowing transfer to a Medigap plan without underwriting until December 31. Hopefully, they will run that promotion again so you can get out of your Advantage Plan.
Tall_AllenTY for your reply.
We met with an insurance agent this morning. We plan to proceed with an expedited appeal for the Lupron scheduled on Wednesday. The insurance agent said we have until March 31st to change plans. He mentioned the BC advantage plan that is the same as a MEDICAP type of policy with no underwriting.
I'm glad to hear that others were approved for the Lupron on appeal.
Inquisitive_One
It sounds like this insurance agent is trying to dupe you. An Advantage Plan is not the same as a Medigap Plan.
Because the agent's commission is far greater selling an advantage plan than a Medicare Plan.
May I ask, what is your insurance? Also what region of the country do you reside?
No need to answer if you feel you want your privacy.
I have Medicare Advantage PPO with United Health Care. I had no issues with approval for Lupron. As you indicated, Medicare covers Lupron for PC ... so there should be no issues.
You did not provide much information about yourself ... but you seem to be on Medicare and dealing with Prostate cancer.
An appeal seems certainly reasonable.
I just don’t understand the monumental disparities in health insurance. I have United Health Medicare Advantage PPO and both my Orgovyx and Xtandi were readily approved.
I agree with Explorer08. I have Medicare Advantage with BCBS in Mass. It is PPO and I asked about pre-approval for radiation, the doctor said that this is SOC. No charge for it and I also had 2 years of Lupron with reasonable co pay. I am always wary but no problems yet.
Perhaps you can ask if they cover eligard same drug, different name. Insurance can be finicky in this way
I have a supplement plus regular Medicare. Covered fully 100%.
Plan D not involved because it's an injection done in MO's office.
sounds like your plan is denying a percentage of orders. United health care is on the carpet for this. They are private. They can approve or deny what they want. But can tell you you get X amt for groceries, the gym, etc. nothing is free, even in network. There is a reason why Mayo of Rochester and Phoenix do not accept them and Jacksonville only a small amt. there is a reason why Medicare advantage aren’t in many net works.
Was it denied because it is a monthly injection and not every 3 months which is typical? If there is a rationale for monthly injections perhaps that can be explained in an appeal.
I’ve heard stories of Advantage plans being very difficult to work with, if the opportunity ever presents itself to go with traditional Medicare, a part D drug plan and a supplemental I think it would be a wise move. I’ve never had issues with traditional Medicare.
Ed
Aetna Medicare Advantage paid for my Lupron. I sometimes wonder if the agents subconsciously deny coverage in hopes to depress the patient to suppress their immune system to a point where the client dies? They know that once a patient is diagnosed with cancer (or, cardiac issues), the insurance company is unlikely to cover their yearly costs from that patient’s premiums. You may need a letter from your MO, but just appeal and do not get upset…
It’s a part b injectable drug covered by Medicare, so your Medicare advantage plan has to cover it as a part b drug because it is given in a hospital or outpatient setting. Don’t let them tell you it’s a part d drug or not covered under your advantage plan. There was a report that the advantage plans were routinely denying coverage that traditional Medicare covers and they were called out by the centers for Medicare and Medicaid for doing that.
A number of comments here hit the important point — lupron is an injection, not a drug. So it’s covered under Part B Medicare. It has nothing to do with Part D.
More importantly in the big picture, you might consider switching over to Medicare + Medigap instead of Advantage, if you can. I have Plan G supplement with Aetna and I’ve had zero problems.
Ditto on the suggestion to look into switching over. There are multiple reports on how poorly the medicare advantage plans are treating some patients, and other reports on how much profit they're making, a good part of which is government subsidies to the plans.
Basically - they suck. Ever actually know someone who took advantage of the "Silver Sneakers" deal they all offer? I looked into it out of curiosity - and the nearest place to go to for Silver Sneakers for me was about 30 miles away, and I live in an area where gyms almost match 7-11's in density.
WTF WTF WTF WTF WTF WTF WTF WTF WTF WTF and WTF
Have you Doctor(s) call those bastards, and to remember to take no prisoners.....
Good Luck, Good Health and Good Humor.
j-o-h-n Friday 01/12/2024 8:31 PM EST
Good News, my husband will be able to receive Lupron. The oncology team at the facility <University of Chicago> followed up with the insurance company, and everything was straightened out. It was the way they submitted the request to our insurance carrier.
Thank you J-o-h-n,
Good deal......Much success....
Good Luck, Good Health and Good Humor.
j-o-h-n Sunday 01/14/2024 3:26 PM EST
TY so much for your support.
Why, if you have prostate cancer, you don't want a medicare advantage plan 
Medicare Advantage Plans Any Tips, Insights or Suggestions?
Did you use Orgovyx with radiation, and did your Medicare Part D or Advantage plan cover it ?Changes in Lupron Medicare guidelines
Monthly co-pay costs for Firmagon/Degarelix shots on Medicare Advantage vs Regular Medicare USA?
