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Houston mother forced to pay triple price for cancer drug after insurance company denies coverage

HOUSTON – Your money or your life -- that’s the choice a Houston nurse and mother said she had to make after her health insurance company refused to pay for an expensive, new cancer drug.

For more than 20 years, Ann Marie O’Callaghan has worked toward one mission: saving other people’s lives. But three years ago Ann got some of the worst news any woman will ever hear: she was told she had stage 3 breast cancer, an especially aggressive form.

“I’m going to start crying if I talk about it. I always cry when I think about it," O'Callaghan said.

Thanks to all of her medical knowledge, and with the care of top cancer doctors at the Baylor College of Medicine in Houston, O’Callaghan beat the killer cancer. But this past summer it came back.

A team of cancer specialists, sometimes called the Tumor Board, told her that her best chance for survival was treatment with a new cancer drug called Perjeta.

“My doctor told me, she said, 'Absolutely, if you do it, I think you’re going to live to be an old lady," O’Callaghan said.

The only problem was that Perjeta is incredibly expensive, O’Callaghan said.

A single dose of 420 milligrams costs about $5,000. Government-run Medicare pays about $4,300 for the drug and insurance companies may pay a negotiated rate as low as $4,100.

But despite Ann’s doctor’s recommendations, her insurance company, Blue Cross Blue Shield Of Texas, refused to pay for that drug, calling it “experimental and investigational” in their denial letter. “There is insufficient evidence establishing the service is generally accepted in the medical community," the letter said.

O’Callaghan appealed the company’s decision several times, but the decision stood.

Without insurance covering the cost, O’Callaghan would have to pay the full bill out of her own pocket

“Pay for the drug or face death from cancer," O’Callaghan said she recalled thinking.

Not only would O’Callaghan have to pay for that drug out of her own pocket, the hospital, Baylor College of Medicine, informed her she would have to pay $12,226 for each dose, or a total of more than $61,000 for five doses.

“That’s almost three times what the insurance company would have paid for that drug," O’Callaghan said. “How does anybody come up with that kind of money?”

Shawn Fry, CE0 of Prevalent, and a medical billing expert who works with hospitals all over the United States, called it ridiculous.

“It’s absolutely outrageous that a woman who has insurance benefits through this plan not be allowed the right to exercise those benefits. It’s the whole purpose of why we have insurance," Fry said.

Now, to put an end to drug price horror stories like O’Callaghan's, Democrat U.S. Rep. Lloyd Doggett of Texas of the 35th Congressional District, recently launched The Affordable Drug Task Force.

A group determined to greatly lower the cost millions of Americans are being forced to pay for lifesaving, life improving drugs.

“The first problem we are trying to deal with in our task force is why, particularly with cancer drugs, but other drugs for diseases like multiple sclerosis, are being priced so high. It really is banditry when it’s your money or your life,” Doggett said.

O’Callaghan said she paid out of her own pocket for the drug Perjeta a total of more than $61,000.

How can you avoid what happened to O’Callaghan?

Fry said it is key that you ask your doctors for a letter of medical necessity. Ask your doctors to help argue for you to the insurance company if that company denies coverage of a drug that has been recommended for you. If you are still denied, Fry said appeal that decision as far as you can. That’s what O’Callaghan is doing.

She is now appealing her case to the Texas State Board of Insurance.

Channel 2 Investigates asked for an on-camera interview with representatives from both Baylor College of Medicine and Blue Cross Blue Shield of Texas, but both declined to talk to us.

Edna Perez, with Vega/Blue Cross Blue Shield of Texas, wrote the following statement:

"In efforts to safeguard our members’ privacy, we don’t comment on specifics of individual cases. We recognize that health related issues can be stressful for individuals and families, so we work as quickly as possible to help all of our members with their questions or concerns about their coverage.

"Blue Cross and Blue Shield of Texas coverage documents describe the appeal process available to members in accordance with state and federal requirements to obtain a full and fair review by BCBSTX of any determination of a claim or any other determination made by BCBSTX of benefits under the Plan.

"With respect to determinations of the medical necessity of a treatment or service, such determinations are made under the direction of a BCBSTX medical director based on applicable BCBSTX medical policy. Prior to any determination to deny the service (adverse determination) the requesting/rendering provider is provided an opportunity to have a peer to peer discussion with the BCBSTX medical director to provide additional information regarding their patient's condition and the need for the services in question.

"If an adverse determination is made, the member, member's representative, or requesting provider can appeal. The appeal will be reviewed by a health care provider not involved in the initial decision, who is in the same or similar specialty that typically manages the medical or dental condition, procedure or treatment under review.

"Notice of BCBSTX's final decision on the appeal will include the dental, medical and contractual reasons for the resolution; clinical basis for the decision and the specialization of Provider consulted. A denial will also include notice of the member's right to have an Independent Review Organization (IRO) review the denial and the procedures to obtain a review.

"The IRO is an organization independent of BCBSTX and performs a final administrative review of an Adverse Determination made by BCBSTX. A member whose appeal of an Adverse Determination is denied may seek review of the decision by an IRO assigned to the appeal by the Texas Department of Insurance.

"The decision of the IRO is binding on BCBSTX and BCBSTX pays for the IRO review. In life-threatening or urgent care circumstances or if the member does not receive a timely decision, an immediate appeal may be made to the IRO and the member is not required to first comply with BCBSTX's appeal of an Adverse Determination process."