Hi Everyone,
As I mentioned in previous posts, my doctor is recommending Enbrel. Right now I have no insurance and no income, so I might qualify for pateint assistance. But I am thinking about the future. I hope this drug can get me feeling good enough to go back to work, which would would kick me out of any assistance program.
My first question is would insurance cover biologicals once I have coverage?
Secondly, are there standard timelimes that must be met on drugs like Plaquenil and MXT before the insur co. would cover these drugs? For example, tomorrow will be my 19th dose of MXT. Just under 5 months. I still have to get the chest X-ray and TB test for Enbrel, so I haven't started it yet. But what if it turns out down the road that I get turned down for coverage b/c I needed to give MXT 6 months?
I would appreciate any help in this matter.
Take care,
Nori
Plaquenil & MTX They do not cost much but the enbrel does like 1,600.00 a month I am sure there is programs out there that would help. You have to ask some of the people on here I am sure they would have some links for oyou.Hi Nori......I hope the Enbrel works for you and as quickly as it did for me. When I started Enbrel I had only been on MTX for maybe 6 to 8 weeks, and had not taken any other medications such as plaquinel. So as far as I know, with my insurance anyway, their was no time frame.
Has yoru doctor given you any info regarding financial assistance with Enbrel? I think I went through Enliven services. Even though I was insured, they picked up the tab for the first 6 months. Now I only pay 30.00 co pay per month.
Mtx is not covered by our insurance and I pay like for a months supply. That is for the injectable kind of mtx. I am not sure what the price of mtx is in the pill form. Here is a website that might be able to help you out. http://www.patientadvocate.org/
http://www.freemedicinerevolution.com/?gclid=CK3k2ffehZECFQw sOAodqF1DHg
https://www.pparx.org/Intro.php
http://www.bioscrip.com/default.aspx?tabid=105
I think she's asking if starting Enbrel under patient assistance mean she has a 'prior condition' and the insurance co. will refuse her later.
Anybody know?
Pip
Hi Everyone,
Thank you for your relplies! To clarify, I tend to think about 10 steps ahead and come up w/ scenarios and try to make decisions based on what 'could' happen. Sometimes it is a great asset for me, mostly it only causes more stress!
A friend of mine mentioned he thought he had read somewhere that insurance companies are reluctant to pay for biologicals unless there has been a real effort to try drugs like MXT first. I've been on plaquenil since Oct '06, and MXT for 18 doses. Now my doctor wants to add Enbrel. While I would probably have no problem getting assistance now, b/c I am not working and have no insurance, I'm thinking about the future. I would like to eventually be able to have the drug covered under insurance.
I thought wouldn't that be horrible, if when I finally had insurance I was turned down for coverage of Enbrel, b/c I only gave MXT 5 months instead of 6? When I had insurance, so much was denied that I just want to give myself the best possible chance of coverage by my actions now. I thought maybe people on this board might have some insight based on their own experiences.
It is scary to hear that such a standard (and cheap) treatment such as MXT wouldn't be covered under grammaskittles' insurance. That seems absurd! When I am able to work again, I will have to look at insurance as my #1 priority even over whether or not I will like the job. I am very depressed over this horrible disease.
Again, I appreciate your time in this matter.
Take care,
Nori
Also, Grammaskittles, thank you for the links. I will check into those. My doctor felt I could get the drug covered under the drug company. But I do have other drugs I'm taking. So it could be helpful!
Also, Pip, I'm not worried about the pre-existing condition clause. I've already got that going on. I have RA and graves disease. More than likely there will be a waiting period b4 the insurance kicks in once I join a company. My only chance is a good job. But I can't do that until I get better. I was actually thinking about starting on remicade (sp?) instead b/c I heard that's cheaper. But I have no idea what to do.
My question is specifically about making sure I have given MXT enough time in the eyes of typical insurance companies for them to say, "OK, we will cover this biological b/c MXT obviously wasn't working for her." I just don't want to be denied in the future when the time comes.
Take care,
Nori
Nori king, call the 800# for the Enbrel they have a program where you can get it for free or a really great discount. My insurance ran out and they are helping me out ALOT.Humira has the same thing going on also.Thank you, Maimi. I will be calling them tomorrow. I had seen that they have a liason w/ insurance companies, so I will ask them their take on a timeline for having to try other meds first.
Take care,
Nori
The Enbrel company did'nt ask me about other meds that I have tried they said all I need is a rx from my Dr . Easy paper work to fill out and there is also one for your Dr to fill out and your Dr's office can fax it right from their office . The people at Enbrel are so nice and will do anything to help you. Good Luck!Nori,
My insurance didn't have a time limit, it only said that I had to have failed at least one other DMARD. I assume it meant that I gave the other DMARD reasonable time for benefit. I don't remember how long it takes to get the full benefit of mtx. Was it 3 months?
Nori-I was on enbrel for a short time and that was the first med I had been on in over 10 years.
I hope you figure something out. I know insurance is such a pain to try and figure out!
Thank you again for your replies. This has been very helpful!
Nori
I have never had any issues at all getting biologics. Of course I have also been on pretty much every drug in existance so they may count that as me "failing" all of those drugs. My insurance pays 80% of an infusion biologic and injectable biologics like Enbrel and Humira I just pay the normal copay of generic, preferred, or brand which is , 40, and 70. Definitely call the Enbrel people and speak with them about it as they should be able to help you and will most likely have a list of insurances which do and do not cover the drug. One good thing about Enbrel is that it is not brand new so many more insurance companies are covering it now than were just a few years ago. Good luck!