When 56-year-old Michele Brough was diagnosed with stage III breast cancer, her doctor immediately applied to her insurance company to get coverage for her treatment. Part of that treatment was an immune-boosting shot of Neulasta Onpro that costs $7,000 per injection and would be needed four times over the course of Michele’s treatment plan.
The insurance company, Anthem, sent a letter back saying her treatment would be covered. “We are pleased to authorize benefits for the service(s),” the letter stated.
Reassured that at least the financial burden was under control, Michele began her chemotherapy regimen, using the $7,000 shots to stimulate the production of white blood cells, ward off infection, and keep her body as healthy as possible during the process.
However, after she had been given two of the four injections, her oncologist told her that the insurance company had refused to pay for the Neulasta Onpro because Michele had not purchased the products herself through the online pharmacy Express Scripts and self-administered them. These two caveats were never mentioned in the coverage letter, nor do they seem to make any sense at all to Michele and her husband, who are now scrambling to find a way to pay for the treatment.
“It just made no sense,” says Darrell Brough, Michele’s husband. “They covered everything else, all the drugs, all the doctor’s visits. But not this?”
Sadly, Michele couldn’t continue her chemotherapy regimen without the Neulasta Onpro injection, and she would have had little hope for survival if she stopped in the middle of treatment. So she was forced to sign a waiver saying she would be responsible for the cost of the shot before the third dose could be administered, allowing her to continue with her life-saving chemotherapy treatment. And, as expected, Anthem denied her claim, placing her further into debt.
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Michele’s immune system was doing well enough by the time the fourth dose was due that her doctor decided it was safe to skip the shot, although it may have been a bit risky for her health. Her advanced stage III cancer gives her about a 72 percent chance of survival over a five-year period—but only if she receives proper treatment. Luckily, she has made it through her fourth round of chemotherapy without any serious complications.
Michele and Darrell weren’t ready to give up their fight with Anthem yet, however. After appeals to the insurance company got them nowhere, they contacted a reporter to try to get more publicity to the case. And it worked.
“When we were recently made aware of a concern pertaining to an oncology drug used by one of our consumers, our team began working to understand what happened and found the claims were processed incorrectly,” says Leslie Porras, an Anthem spokesperson. “Since the member first contacted us, we have been working with all parties involved to coordinate and resolve this matter.”
The Broughs later found out all three injections would be covered in full. They were able to reap the benefits of their hard work and force the insurance company to admit that it had made a mistake. But nobody—particularly people going through expensive treatment for life-threatening diseases—should ever have to put this much effort into convincing an insurance company to do what they promised to do.Whizzco