During chemo I have nausea. Zofran & Compazine haven't worked. Emend helped but is expensive. How can I negotiate with my insurance company to pay for Emend?

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PatientAdvocateFoundation (Organization (Verified) ) - 07 / 26 / 2012

If you are requesting a medication that is off your prescription drug plan’s formulary, you will want to check with your insurance provider to determine what the process is to request an individual exception. Many health plans will give you the opportunity to request an exception based on medical necessity. For example, the medical necessity of you requesting Emend is that the alternative therapies, Zofran and Compazine, either did not work for you or that you experienced adverse reactions to them. You may want to ask your doctor to write a short letter to support your request.
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member9844 (Friend) - 07 / 25 / 2011

First you need to ask your doc if there is anything that is a generic that's comparable to Emend. The price of Emend may be a function of its place on your Pharmacy plan's Formulary, and, as such may be in a Tiered Plan situation where certain inexpensive drugs are made more accessible, and as the complexity and expense of the drugs go up so may your co-pay. If there is no comparable drug to Emend, and if this is truly the only med to work for you, then you'd get a letter of medical necessity from your doc over to the PBM/Managed Care Org. with a request to keep the patient expense to a minimum. In the interim, I would call the Managed Care Org. and ask to speak to the CEO's office ("I'd like Joe Smithers office please.") Then you explain your situation to the assistant and ask for a remedy as it's an expensive drug. Also, I'd contact your company's HR/Benefits people to see if they can suggest a remedy for you as they took part in purchasing the plan. Use as much emotional leverage as you can here. I wish you luck.

member5693 (Survivor (2 - 5 years)) - 07 / 25 / 2011

My insurance wouldn't pay either, but Merck had a program to furnish it to patients in those circumstances. Don't think we ever had to buy a single dose - they mailed them to me before each scheduled chemo. Your doc should contact them for you an arrange that.
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