Dealing with insurance companies

Avatar for Cmmelissa
iVillage Member
Registered: 11-13-2008
Dealing with insurance companies
Tue, 07-16-2013 - 4:07pm

The Today Show had a story today about siblings, both with the same gene mutation of CF, the same doctor and the same insurnace company.  While the sister was approved for Kalydeco, the brother was denied coverage.  He battled with the insurance company, was denied four times, and did not get approved until his insurance company was contacted by Today.

It seems like they make their decisions so arbitrarily, what do you think of the story?  Have you had trouble getting coverage for your child?

Avatar for adamsmomplus2
iVillage Member
Registered: 09-09-2000
Wed, 07-24-2013 - 3:59pm

I feel like we're not getting the whole story with this one. Kalydeco is currently only approved for individuals with the G551D mutation. Since the insurance company issued one denial based on the type of mutation, it sounds like neither of them has this mutation. Doctors prescribe medication outside of approved FDA use all the time, however, in this case, it sounds  like the requests were reviewed by different people who came to different conclusions about the appropriateness of the medication. Also, even if they have the same insurance company, that doesn't mean they have the same plan. I know many people with the same insurance I have and we pay vastly different amounts for things based on our plan. So, the specifics of the plan, what drugs are covered, etc., may play into this as well.