Denied | Arthritis Information

 

  Hi all.

My insurance company denied the doctor's prescription for Humira today. I'm not surprised - some of you warned me they wouldn't like it. I still have to vent for 2 reasons:

1. This doctor (and I really do like her) is the only one the insurance company allows in my area. I HAVE to go to her, but I'm not allowed to take the medicine she prescribes. Does that make sense?

2. It took them more than a week to make this decision. If they'd said no right away, I could have been looking at other options all this time. I'm only only 10 mg. of prednisone, because we were planning on not using it much longer. I'm going to have to up the dose, because I'm becoming less & less functional.

I know once I get in the system, they'll eventually take care of me. This is just killing me, though. It means more trips to the doctor (it's about an hour & a half out of a day. I know, not a biggie compared with a lot of what you go through - but it's unnecessary). It means I have to bump my prednisone back up to 15 mg. until I get in to see the doctor again, and it's been 4 months since I was diagnosed, and I haven't been put on ANYTHING while I wait except the prednisone. I am beyond frustrated. So many of you have problems with your doctors. I really don't they've been great. It's the insurance company that is (maybe literally) killing me

Thanks for listening.
I hate insurance companies.  They have zero problem taking everyone else's money.  I really find it to be such an insult.  We are the little guy.

http://www.arthritisinsight.com/archives/test231.htm

Try those links for those places.  Maybe you could get lucky and find some help with the cost of your medications so you can try it out.


Thanks, AZ. I could try, but I have insurance, and so many people don't - I think people who don't have alternatives should get first crack at them. My doctor will probably prescribe methotrexate for me. She doesn't think it will work, and I don't know why. I have to have the shots - I don't tolerate pills and never have. Can't take pain killers. Couldn't tolerate Vioxx. We'll try this, and if it doesn't work, then the insurance co. will have a hard time refusing coverage. It's just - they decide who my doctors will be, but then they don't want to follow my doctor's decisions, and they're wasting so much time. Upping the prednisone isn't a good thing, but if I don't, I won't be walking next week. Sigh.

The disease is frustrating, but as we're all so aware, it isn't just the disease. It's the doctors, the insurance companies, the paperwork, the bureaucracy. Double sigh..

You are right...  They tell you to go to one particular doctor then THEY (the insurance company) tells the MD what they want done.   Who went to medical school.   My RD and I talk about this each visit.   Thankfully, my insurance company has learned to listen to her and my other specialists.   Otherwise they end up paying for more than what they initially would have.  

So sorry Fiona,

I hate it when the Insurance companies rule, but they do.  I had a similar situation. I'm allergic to everything including all NSAIDS, sulfa, penicillin, aspirin. I can take only one antibiotic. I was started with prednisone, then plaquanil, methetrexate, and finally enbrel.  The insurance wouldn't let me have the enbrel until I'd exhasusted all the other cheaper possibilities. Now I'm on all of them. I immagine the same thing will happen to you. The doctor has to prove that you've been unresponsive to everything else before they bring out the heavy artillary(enbrel ,humira, remicade,etc...) Enbrel costs about 0. pre shot.

Fifi, maybe you can call the doctors office and they can call in a RX for somthing else so you wont have to go back in to the office...The problem I see is, Methotrexate (or whatever the doctor prescribes, but I'm guessing it will be MTX) is not benign. It's toxic. So, in order to please the insurance company, I'm going to be forced to take, quite literally, poison. Of course, these are all poisons. We know that. But I'm going to be forced to take a poison that MY DOCTOR, not I, doesn't believe is going to work.

Apart from RA, I'm a very healthy person (okay acid reflux going on here, but nothing else), but I'm going to be forced to take a drug that may destroy my bones, bone marrow, kidneys, liver, mouth. It may cause internal bleeding. It may kill me. And my doctor doesn't believe it's going to work.

Apart from the fact that whatever placebo effect there might have been will be gone, this is unethical! And it opens the insurance company up to a world of lawsuits. What if I get really sick on this drug after my doctor has said I shouldn't use it? I just don't understand why they would do it. Yet, we all put up with it because we have no choice. We have to have something. We have to jump through the hoops.

You've all been there, I know that. You've all gone through some version of this. And I know, one drug might well work as well as another. But what do you need doctors for, if the insurance companies are going to ignore them? I just don't get it.
I am so sorry that the insurance company is doing this to you. I have my next RA appointment this Tuesday and I'm afraid he's going to put me on another med such as what you've been talking about. I will be in the same boat as you since I have checked my presciption list and the co-pays etc.. Most of the RA drugs are a prior auth required or are just not covered at all. Insurance companies have no problem taking our money but when we need something from them they don't want to help. What to do??

Fiona, why don't you ask your doctor to explain why she doesn't think it will work?  I'm on all 3 of the usual's.  Placquenil, mtx,and now, remicade.  He (rheumy doesn't want to take me off of any).  And just night before last, I have a friend at work come up to me, and he said that he had just heard about me haveing it.  In l990, he was dx'd with ra, and was put on mtx at 5 mgs a day and has been "cured" since that time.   And from what I can find on the internet, mtx is still considered to be the main first shot at helping us.

Hope you're all better soon, mary

 

 

Fiona, lol, this is really a ps..forgot to mention that takeing all drugs is so very scarey, they HAVE to list all the bad possibilities.  I've been taking methotrexate for 10 mos. now, and haven't had any problems so far.  I've been lucky enough to not be sick with it. [QUOTE=Fiona] Thanks, AZ. I could try, but I have insurance, and so
many people don't - I think people who don't have alternatives should get
first crack at them. My doctor will probably prescribe methotrexate for
me. She doesn't think it will work, and I don't know why. I have to have
the shots - I don't tolerate pills and never have. Can't take pain killers.
Couldn't tolerate Vioxx. We'll try this, and if it doesn't work, then the
insurance co. will have a hard time refusing coverage. It's just - they
decide who my doctors will be, but then they don't want to follow my
doctor's decisions, and they're wasting so much time. Upping the
prednisone isn't a good thing, but if I don't, I won't be walking next week.
Sigh. The disease is frustrating, but as we're all so aware, it isn't just the
disease. It's the doctors, the insurance companies, the paperwork, the
bureaucracy. Double sigh..
[/QUOTE]


Have you thought about making a trip to the insurance company office
and talking to someone in person, letting them know just how miserable
you are and how important it is to receive this medicine? I think if some
of these pencil pushers could see what REALLY goes on with patients,
they would maybe have a change of heart...or maybe not. I'm really over
the whole insurance system. As a nurse, I see it every day at work.

Good thinking Lorster. Sometimes it is harder to deny treatment to a name with a face. I have no major complaints about the MTX (yet) and I also understand it to be the standard first treatment for RA and the drug by which all others are compared in terms of RA. The system is frustrating and it is prob. true that ins. co. count on the fact that most people dont have the time or energy to dispute their desicions. Hospitals have patient advocates...do health insurance companies? Who decides whether what they decide is ethical or not? If you do decide to fight this Fifi, you are fighting a fight for many as well as yourself. If you are going to fight it, the doctor really needs to back you up. Talk to her first. Good luck girl!

These are all really good points - but, if I dispute their decision, I'll probably end up waiting at least another month for any treatment. I have a dr's. appointment for Friday (because I have to have a referral to see the doctor, & it takes 72 hours to get, and then they have to have an opening), so if we appeal, it'll be another 2 weeks before they decide on the appeal, and then, if they approve it, it's another week before they get in the Humira, and then I have to schedule the appt. for the first injection. If I go on Friday & take something else, it'll (I hope) be done. I'll get the medicine next week and can start doing something. The time passing is starting to really worry me. 

I think you should all come down to Australia.  No insurance companies to fight with

I feel so much for you (all) having to fight this (so unecessary)

Keep plugging away, somethig has to give. Hope it is soon

I've been to Oz, Pammy. I have cousins in Sydney. Beautiful place! Hard to believe I trekked all over the place - climbed the Harbour Bridge. Can't imagine doing that now.

You are options are not at an end on the Humira. Your doctor has the option of helping you get Patience Assistance for any  of these medications: Enbrel, Remicade, etc. Your doctor can try one of these others or because you have been officially denied by your insurance, sometimes the Patient Assistant programs will pay for them. However, the doctor's staff might not follow up on this if you don't push it. You also can push it with the insurance.

Mtx is not as bad as your doctor seems to indicate. If you research carefully on the Internet, you will find is used successfully without all those side effects. The key is that your doctor monitors it carefully with consistent blood tests. This will alert them to developing problems. Most problems go away if the drug is stopped.

If your doctor isn't going to pursue this further, then I believe you have the right to ask for another doctor. If you get resistance for the insurance company about that, then call your State Insurance board. Maybe they aren't playing by the rules. They wouldn't do that, would they?

Just don't give up. There are lots of options.

My doctor seems to use passive aggression. She said that at the first sign that anything isn't working right (see what's happening w/Arizonara), we go off it immediately, and they will HAVE to authorize the Humira. She said she's worked with this insurance company quite a bit. Half the time, the approval sails through. Half the time, you have to go through this rigamarole. She said that for some people, MTX is a lifesaver, but for most that she's worked with, Humira is a better answer.

I read about MTX, and read Lovie's info (recommending that you try MTX and stay on it as long as possible, if it works), and read the Johns Hopkins info on it, and decided that I should at least give it a try. The price difference between the two drugs is HUGE. I wouldn't get the patient assistance anyway. I can't afford to pay for Humira on my own, but I think we make too much for help - and there are people who really need that.

There are other, more complicated reasons, also, that I won't go into here. I appreciate everyone's support, though. My biggest frustration was that, because of the HMO's rules, it took me 4 months to get on ANYTHING, and that was starting to become frightening.

Income is not the only thing that Patient Assistance looks at. Sometimes they also look at denials.

And, yes, insurance companies do have patient advocates. I have used these very successfully in the past. They can really ride on someone who is more interested in being bureaucratic and human.

It shouldn't hurt to start the mtx while you sort this out. But mtx does not work as quickly as the biologics.

HMOs are the worst and I won't go on one in the future. Everything is designed for four months approval. They nearly killed me with that when I first got sick. But that's where the patient advocate comes in. There is also outside groups, similar to Patient Assistance, that will advocate for you. They look at the rules of the HMO, will make calls, etc. and if there is anyting that they can do, they will. They are really nice. Just look up Patient Advocate on the Internet.

If you can't find the info and want it, let me know and I'll dig through my stuff for it.

Four months is critical. But do all the other things that you can. Rest more. Take all the vitamins your doctor suggests. Eat well. Reduce your stress. If you can take some time off work, even a day or two it can help. Since you can't take pain killers, use all the other available methods: ice, heat, sports creme. Swimming is extraordinarily good for you and has the least impact on your limbs.

I also went with a fitness trainer at the gym who worked with my doctor to get me better. Physical therapy and fitness training can help get blood back to those joints and strengthen your muscles.

Whatever, don't give up. You deserve good treatment just like anybody else. Once you get it, then you can help others who need it. Try and think about it that way. You do deserve to get the medical care you need, no matter income or special circumstances.

Try the Mthx--I know it is a scary drug but it does help and they do watch you carefully with the blood tests.  The insurance company will not consider the biologics until you try the methx and your numbers don't improve.  I had to go through it to get Humira.  However, I also take 20mg of mthx each week.  If you truly have RA and want help with the pain and stopping the damage it does, you will have to exhaust all the drugs.  The Humira costs about ,000 a year--I thought I heard Remicade runs about ,000 a year--I was really amazed mine was approve.  When the pharmacist told me how much it costs, I just laughed--what else could I do--it sounded so rediculous.  Good luck.   
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