Welthy Posted August 29, 2007 Share Posted August 29, 2007 This isn't official news, but have learned through our Oncologist, that brand new rules and regs have occurred for Medicare patients taking Procrit in the past 2-3 weeks. They now cannot start Procrit until the hemoglobin drops below 10.0. (It used to be 12.0) If the patient doesn't respond with at least a one point bump at 40,000 dosage in 4 weeks it gets a little blurry as to what Medicare will cover. The Procrit Rep was at our oncologist while we were there on Monday prepping the staff about the new rules. Medicare used to allow a larger dosage (60,000) after 4 weeks with low response. They may allow coverage for a bump to 50,000 dosage, but we left the office before confirming that information. The nurses were under the impression that without seeing significant improvement, Medicare will yank coverage for ANY procrit for a given patient. Apparently this is Medicare's second knee-jerk reaction to the possible side effects of trying to over-enhance the hemoglobin counts that was reported earlier this year. Our nurses feel this will lead to far more blood transfusions happening as Medicare nukes the blood enhancer options. (I don't know how this applies to Aranesp, but it may also impact the use of that enhancer too.) No Medicare coverage adjustments have been made to the WBC enhancers. Just a perspective from our nurses/oncologist that I thought Medicare folks should know. For us, it comes at a bad time. Until very recently Tony's counts were always great, but suddenly his hemoglobin has taken a nose-dive. Timing is everything --- geez. I'll try to get the full lowdown next visit. Welthy Quote Link to comment Share on other sites More sharing options...
laban Posted August 29, 2007 Share Posted August 29, 2007 That sucks, but we were warned that this was most likely going to happen. Bill gets Aranesp but I'm sure that is included in the RBC enhancers. Since Bill has practically refused to ever get another blood transfusion, I wonder where this will lead. Sorry Tony is having more problems. Blessings to you both and thanks for the update. Quote Link to comment Share on other sites More sharing options...
Linda661 Posted August 31, 2007 Share Posted August 31, 2007 How horrifying to read this -- it's bad enough when the blood transfusions have to happen even with Procrit/Aranesp support. And lowering the value at which it can even be given for coverage in the first place? That's just trash and certainly not in the patient's best treatment interest. Linda Quote Link to comment Share on other sites More sharing options...
blueeye Posted September 1, 2007 Share Posted September 1, 2007 Oh I am so steamed about this!!! We weren't even warned last week. I knew that Mom's H&H was the same as the previous round and she got the Procrit but this time she didn't. The nurse said that her counts were high enough. What she meant was that her counts were too high for Medicare to pay for it! This week her hgb dropped from 10.3 last week to 8.8 so she got two units of blood--and a Procrit shot once I made some noise. I am not opposed to her getting blood (I am a blood bank tech!) but I would like to limit it. We may buy it next round if she needs it and I'll give it to her at home. The oncology center bills Procrit at $2400 a shot and we can get it for $194.37. What's up with that?? And what I read today said that Aranesp is also included. Quote Link to comment Share on other sites More sharing options...
laban Posted September 1, 2007 Share Posted September 1, 2007 Bill had a HGB of 10.6 on Thursday and got an Aranesp shot. Nothing was said by the nurse and I kept my mouth shut. Quote Link to comment Share on other sites More sharing options...
Welthy Posted September 1, 2007 Author Share Posted September 1, 2007 The danger financially is that if the offices don't know the new rules, we could be left swinging in the breeze for payments on these shots. Aranesp may have different criteria. I know there was a "phasing in" window, but I think it is over. Could be wrong. Our office wanted to up the dosage for Tony last week, but was afraid to because they weren't sure it would be covered. Blueeye -- 194.37?? Wow, talk about ridiculous!! I do know that Medicare doesn't pay anywhere near the 2400.00 billing rate though. Welthy Quote Link to comment Share on other sites More sharing options...
twodogs Posted September 1, 2007 Share Posted September 1, 2007 I was so eager for a ruling change I misread the post. I thought it said the ruling was relaxed. I had been on Epogen for four years and recently had to go on transfusions due to this ruling. So far I've had two, (for sure) , rounds of three units each time. If we make it to the Cancer center by 8:00 AM for blood work we're usually out between 4:00 and 6:00 PM. That's a pretty darn long day with chemo in one arm and blood in the other. Quote Link to comment Share on other sites More sharing options...
blueeye Posted September 2, 2007 Share Posted September 2, 2007 Twodogs-that's my issue too. A whole extra day at the clinic. Quote Link to comment Share on other sites More sharing options...
Welthy Posted September 4, 2007 Author Share Posted September 4, 2007 Info at office today stays as above. Some areas still sketchy. Only other mention was if you have no success on Procrit, they won't let you try Aranesp (and vice-versa). Our nurses are frustrated because some patients will actually respond to one after the other, but the option is no longer available. 60,000 dosage of Procrit is out altogether -- 50,000 is the new "high" now. (Regular dosage is 40k.) It's all about showing improvement or even stability on the enhancers. It took my husband 5-6 weeks of Procrit to finally get the "bump", so where does that leave people under the new rules? Bad news. Best wishes to all of us -- survivors and caretakers alike! I'm sorry that Medicare has to add to your troubles. Welthy Quote Link to comment Share on other sites More sharing options...
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