Insurance denied "Tobi" inhaled tobramycin

Appeal. Medicare has a very good process for this.

Have your doctor try to get it through for you as “medically necessary.” Good luck. Irene5

I agree.

Medicare paid part of the course for tobi, united health care supplement paid the rest.

I didn’t have any problems at all.
Just make sure to go to Medicare first.

@fjc0830 I also have pseudomonas as well as United Health Care. When first scripted Tobi, my pharmacy told me that my monthly cost was over $500. My pharmacist 'got around" that by filling it with an IV solution of Tobramycin and giving me direction on how to pull syringe quantities to nebulize. (they do this in hospitals to reduce costs) It cost me $0. As it turned out, it was difficult to tolerate and I was only able to do 2 weeks. The next time it was prescribed, my pharmacist had my Pulmo's amend the script and it was filled with a generic Tobi...TOBRAMYCIN INHALATION SOLUTION, by LUPIN PHARMACEUTICALS in a 300mg/5ml ampule form. (for inhalation only) I cannot recall but I think it might have cost Out of Pocket maybe $20 for a 2 week supply. The pharmacist thought this might be easier on my throat as it is "buffered" as opposed to the IV solution broken down for nebulizing. HA...It actually was worse and I only accomplished 3 days of it. I have a new Pulmonologist and I will be curious to see what he prescribes as I told him I am unable to take the Tobi. Many can handle it, I cannot. Good luck. Kate

I too am covered by United Health. I am 63 so I do not quality for Medicare. It took me about 7 weeks of daily phonecalls between UHC, CVS Specialty Pharmacy and my provider at Mayo Clinic but I FINALLY got it approved at no cost. It was worth the battle. The Tobi has been a game changer for me! Dont give up!

Sue. Is that Medicare with a drug supplement--Medicare D? I did not have "D" but had Blue Cross as well as Medicare. Blue cross paid OK for about 3 years, then, I guess they made changes the first of last year. I tried to get help/answers from them but it was like talking to folks in a ping pong tournament. You get so bounced around that at some point you just give up. I don't like being that person but life is short and the fight is too much to deal with. Thanks for letting me rant. Faye

When I was prescribed Toby it was totally covered by Medicare Part B. Could be my supplemental picked up some of the cost but I never had to pay anything. But I could not tolerate the Toby so only ordered it that once.

Faye - Oh Yes! Blue Cross for Medicare made BIG changes to drug coverage on January 1st. We were assured it would be "transparent" to us. It has been anything but - drugs we have taken for years were denied as "not medically necessary." Our doctors had to send "proof" that we had failed other forms of treatment before they would approve the medication for ONE YEAR (these are for chronic conditions and we will likely need them for the rest of our lives.)

Then they reassigned the meds to a higher tier in the formulary (these are not new drugs, one even has a generic version available) so the co-pay is higher. They also stopped providing a 90-day supply through the Mail Order Pharmacy service, leaving us to go out on our own and try to find them available locally. And, if I read my information correctly, I get to do this all over again in January - this time with 4 or 5 meds, not just two. Yippee.

As Irene noted, by Medicare rules, inhaled drugs fall under Medicare Part B, not D. So they should pay 80% and any supplement you have should pick up most of the rest.

But the Medicare appeal process is the same in any case - the organization that denies the coverage must provide you the forms to fill out for appeal, and the address, email link and phone number for where to send it. And depending on the issue, they must answer your appeal within 14 calendar days or 7 business days.

Sue, you're a treasure. Thanks so much for this information. I'll have to go back over my notes on what departments, etc. I've spoken with and try again. I know there are deadlines in filing appeals. Appreciate your wisdom and dedication to this group. Faye