Topic: Anyone have TRICARE deny the Oncotype test?

Forum: Employment, Insurance, and Other Financial Issues — Employment, insurance, and financial concerns are common. Meet others here to discuss and for support.

Posted on: Aug 13, 2010 06:35PM

Posted on: Aug 13, 2010 06:35PM

ToriGirl wrote:

Just wondering if anyone has Tricare insurance and had their oncotype test denied?  Were you able to repeal it and how did you do it? 

The bill is enormous!

Any suggestions would be so helpful! 

Thanks so much!

Tori

"Sorrow carves the opening for joy later..." Dx 6/4/2010, IDC, 1cm, Stage IIA, 1/11 nodes, ER+/PR+, HER2-
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Aug 13, 2010 08:50PM - edited Aug 13, 2010 08:51PM by nowords

I had Tricare and early on I had a case manager assigned to me.She told me it was important to get pre-approval for some tests.  I know I was told that my chances of having chemo be effective were 1 to 3 %, but do not recall if they ordered the oncotype test...I could dig out my old records and check. I have Tricare Standard and a supplemnt from FRA. I had treatment at Mayo Clinic and they did not deny anything. I had BRAC 1 and 2 test, Tamox metabolizer test, tons of blood work, an emergency room visit in the middle of chemo, chemo, nuelasta shots, Bone Scan, PET, MRI, ultra-sounds xrays, muga scans and stress tests as well as surgery rads and some PT and lymphedema Clinic preventative appts. I met my deductible and Mayo took what Champus and my supplement paid. 

There are a few other ladies with Tricare on the boards who may be able to offer info.

I once had a rough time getting them to pay something for my daughter. After 4 letters and many phone calls, the last letter I wrote I referenced copying my State Senators and mentioned that they would be interested to know how the family of a 20 year Veteran is being given the runaround. They paid in full in a week.

I would ask the Dr. who ordered the test to help...maybe write the justification for the test and to contact Tricare with you there.

Dx 4/6/2009, ILC, 6cm+, Stage IIIA, Grade 1, 7/22 nodes, ER+/PR+, HER2-
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Aug 15, 2010 11:13AM MaryNY wrote:

I had Aetna and they denied coverage for the test. They cover the test for node-negative ER+ women but I had two positive nodes. I spoke to someone at Genomic Health before I got the test results and said I was afraid the my insurance company might not cover the test. They told me that they had a financial assistance program which could help cover all or most of the cost if insurance was denied. I never received a bill from them. I'm guessing doctor did write a good letter justifying the test.

It may be worth your while calling Genomic directly. I found them really great to deal with. I had a few calls with them as my test was delayed owing to pathology samples not being sent out on time. 

Mary ~~ lumpectomy 8/10/2009, Oncotype DX 18, Chemo 10/28/09--2/1/10 AC*4, CMF*4 Dx 5/19/2009, IDC, 1cm, Stage IIA, Grade 2, 2/6 nodes, ER+/PR+, HER2-
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Aug 20, 2010 05:56AM Julie50 wrote:

Tori:  I have PHCS and they are telling me I have to pay $1,600 of the bill, I think not.  We are fighting it at the moment as my insurance.  You just have to have the dr's fill out tons of forms and send them in, I'm still waiting on this.

Dx 5/17/2010, IDC, 2cm, Stage I, Grade 2, ER+/PR+, HER2-
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Sep 19, 2010 02:52PM phxsunshine wrote:

I have Tricare and just got the denial of payment. The lady I spoke to at the Oncotype lab warned me that they would need to appeal it and that Tricare has usually been picking up 86% of the bill and that I'd be responsible for the rest - this was before they had received my sample - and they had several ways for me to be able to cover it.  The Oncotype lady is also a military spouse and she knew exactly what she was talking about, so I hope you have appealed it by now.

Lumpectomy & re-excision, Oncotype DX score 8, no chemo. Canadian protocol rads. Dx 5/24/2010, IDC, 1cm, Stage IB, Grade 2, 0/1 nodes, ER+/PR+, HER2- Surgery 6/10/2010 Lumpectomy: Left; Lymph node removal: Left, Sentinel Surgery 6/21/2010 Lumpectomy: Left Radiation Therapy 8/12/2010 Breast Hormonal Therapy 9/12/2010 Hormonal Therapy 2/13/2011 Femara (letrozole) Hormonal Therapy 7/5/2012 Aromasin (exemestane) Hormonal Therapy 8/30/2012 Arimidex (anastrozole) Hormonal Therapy 10/3/2012
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Sep 19, 2010 04:09PM - edited Sep 19, 2010 04:10PM by ToriGirl

Thank you phxsunshine.  I actually got a letter from Genomic Health saying that they were going to appeal it for me.  I am just waiting to hear what the outcome is.  I'd be happy if Tricare paid the 86%...I'd be fine paying the remaining $560 out of the $4000.  I will keep you in the loop and would love to hear from you as well.

Take care, hugs, and prayers,

Tori

P.S.  I know that Genomic Health has payment plans, so that makes it even better.

"Sorrow carves the opening for joy later..." Dx 6/4/2010, IDC, 1cm, Stage IIA, 1/11 nodes, ER+/PR+, HER2-
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Sep 19, 2010 04:43PM rockwell_girl wrote:

When I had the test done in March of 08 they had funding to pay it if you full if in a certain bracket.  I think it might have been under $70,000 for a family of 4.  Finally I got insurace to pay it but was nice to find out I won't have to pay it if insurance won't.  This test is so important, told me no chemo : )

Sandy/Sunshine : ) Dx 3/4/2008, IDC, 1cm, Stage I, Grade 1, 0/2 nodes, ER+/PR+, HER2-
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Sep 19, 2010 05:24PM ToriGirl wrote:

Thank you rockwll_girl...I appreciate your response.  I love that so many folks are able to give me advice, support, and suggestions with things like this!

Take care,

Tori

"Sorrow carves the opening for joy later..." Dx 6/4/2010, IDC, 1cm, Stage IIA, 1/11 nodes, ER+/PR+, HER2-

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