No More MTX Insurance--HELP! | Arthritis Information

I just filled my MTX prescription and learned that my insurance company, in its infinite wisdom, as decided to no longer cover this medication. I now have to write a letter of appeal to try and get it reinstated. I've never had this experience before and I have no idea how successful I will be. Of course I'll write the obvious...that I need it to live a decent life, I have no other choice for now (hopefully if I can start AP it will eliminate the need for the MTX eventually, but not yet) and anything else I can throw at them.

Man, I'm loaded for bear on this. You can always get nasty later... but if you start out firing at them with a missle launcher, where do you go from there? Jesse, the two different insurances that I have been on since the monster struck, neither covered MTX. I never faught it because my battles have been for the TNFs. MTX is cheap, you might want to rethink fighting such a small battle as they do take energy that could be spent on something else.

My injections cost a week, and I get 100 needles for . A tiny cost compared to my TNF costs.

Hi Jesse,

I had this happen to me on another medication a few years ago. I called my Doctor and he got it all straightened out. Perhaps you can call your Dr. and let them handle it. With the way insurance is today, the doctors are used to this and it usually requires a response from them to get your med covered. Good luck and keep us posted...Flo

edited for spelling

hiking_gal2008-08-07 13:35:12are they not covering methotrexate or not covering methotrexate injectable? My insurance said they didn't cover injectables. I won the battle for injectable mtx by using a couple of arguments. Firstly methotrxate was on the forumlary. No where on our drug plan did it state that injectables weren't covered. The cost of the injectable is equivilant to the pill form. and through the speciality pharmacy injectable medications were covered. I called again just to make sure it wasn't a screw-up. It's true that sometimes I'll get a different answer every time I talk to a different person. But this time they agreed. No more MTX coverage.

We pay 4 a month for insurance, plus what my husband's former employer pays, and they can't even pay for a cheap generic? I'm sorry, the principle of this is more important than what I have to pay, and whether or not I can afford to pay. If I don't fight this, what next? If it was a medication I could switch out to something else, or if they were just demanding I take a generic, or if I could get along pretty well without it....those are reasons to reconsider fighting this. Or, if they were being good about paying for another, more expensive drug. But the generic Plaquenil I take is also cheap. No, I'm going to the mat on this one. The powers that be just keep chipping away at our benefits and I'm so totally sick of it.

The first rep said to send a letter. The second rep said I needed to fill out a form that they will send me. I'll compose a letter to go with the form. It will be reviewed by the company's benefits department and Medco. I'll ask my RD to intervene too (good suggestion!).

Buckeye, I was told it's no longer covered....period. They didn't even tell me this was going to happen. What is a specialty pharmacy? Is that mail order? I don't have a list of approved drugs but I'll get one. That's a good argument that I can use. Thanks!I don't have insurance because it pays for nothing when you need it. Hope you get it straighten out honeySeems crazy to me that they would remove mtx, it's not that expensive. Do they still cover avara, plaq, etc. They gave no reason for just the mtx? If your husband's employer was self-insured and you have a contact at the benefits dept, you should give them a call as well. In the end, they're paying the cost if people take a different, possible more expensive med if they can't have mtx.

We have a specialty pharmacy for injectables, but just the biologics and others high-buck ones for various conditions. The mtx inject is covered under the regular script plan. I'd be surprised if they moved your mtx injection to the specialty list given the inexpensive cost, but worth checking out.

Good luck

That's not good.

It is a relatively cheap med... I don't get that at all..

I hope you can work this out...and I'm with you.. fight it!!!

Jesse, I find that to just be weird. I cannot think of a single reason why you were cut off, and it borders on maybe needing an attorney in the future. Morons. :) justsaynoemore2008-08-07 17:31:25

An insurer can drop a drug off their drug formulary list whenever they choose. Recently, my osteoporosis drug was dropped, but I successfully appealed, though I pay a higher copay than if I went with a osteo drug on their formulary list.

I've been on mtx since 1986, first pills, than injectable. There was a period of time when injectable mtx wasn't being manufactured. When it became available again, it no longer was on the drug formulary list and no longer covered by my insurance (though pills were). Since its not an expensive med, I didn't challenge it. It hasn't been covered by my insurance plan for years.

Many insurance companies have pharmacy benefit managers -- like Medco, Caremark -- that handle the drug part of the health insurance plan. PBMs can get "rebates" from drug manufacturers if their drug is included on the drug formulary list. I'm just guessin' here, but perhaps mtx doesn't have much of a profit margin, hence its not worthwhile to include on the formulary.

My concern about insurance coverage of prescription drugs, is expensive drugs like biologics or specialty drugs. As health care costs increase, will insurance companies, PBMs, require higher copays? Some insurance companies require patients to pay 1/3 of the actual cost, for a drug like enbrel, that could be around 0.

My concern is the same as Joy. The cost of biologics is going to force companies to take a 2nd look at how the benefit is set up. The specialty drug utilization is expected to grow much faster than other groups, 15-20% if I remember correctly. Right now at our company enbrel/humira are among the top five in cost, probably closer to 2 or 3. We just switched to a specialty network for those drugs in 2008 - not a change in copay, still pay the same as other formulary meds, but no mailorder, so you are paying an add'l month. I'm not going to complain because it's still a bargain, but if there is a decision to move to coinsurance, that will be difficult to swallow. Joie, if you're right about the MTX not having much of a profit margin, that could very well explain what's going on. Why else would they drop such a cheap drug?

My third call to Medco resulted in yet another story. This guy said the pills are covered, but not the injectible. That's not what the first two said. Geeze! Try to get a straight answer! I guess I'm lucky that this is the first time I've had a real issue with our insurance. I've seen benefits get chipped away over the years, but until now we weren't affected by it. I can't help but think of the people who are dependent on a very expensive drug that they absolutely must have but can't get insurance payment for it. What a terrible position to be in. I know this is why the socialized medicine topic keeps cropping up now and again. We need a system somewhere between what we have now and socialized medicine. I don't see that in our near future though.

In the meantime, I'll fight the good fight and see what happens. Thanks board buddies! I'll use your suggestions.

work with your benefits people...I took my battle all the up the line to the VP of benefits for our company..be that squeaky wheel

good luck

I had an insurance issue once - my rheumatologist prescribed Lunesta and the insurance company preferred another sleep aid (generic ambien, I think). My doctor called them up and told them the reasons for her choice, and cleared the whole thing up before I even knew there was an issue. Jesse, I also take Mtx too and can't imagine why it wouldn't be covered as it is an inexpensive drug. I get mine at Walmart on their 4.00 plan.
I wish you luck with the insurance company.
Mom2
I just love how you get a different answer every time you talk to a new rep......

My hubby had this problem before with our insurance co decided not to cover his insulin. We couldn't believe they wouldn't cover it. He called the insurance company and spoke to a manager and told them since they have decided not to cover a medication he needed to live his dr decided to sign him into the hospital every day for his medication. The coverage cost for the hospital stay would cost them more than covering a months supply of his insulin. Once this was followed by a call from our Dr the insurace co backed down and covered his humalog. They (the insurance co)wanted him to take a different form of insulin that had stopped working for him.

The insurance companies burn me up.

Lorried, your husband's response was brilliant! I got a great laugh out of it and the satisfaction of knowing the insurance company lost that battle.

Thank you all for your suppport and comments. Just being able to vent to all of you made me feel so much better, and once I kick some insurance butt I'll feel even better!!!