Insurance/no treatment!! | Arthritis Information

I just called my doctor and told the nurse I can't 'get off of (reduce )the prednisone' without pain and stiffness. Last month the doctor told me if this happened he would give me more Remicade. Guess what!???? The insurance will not pay for more until NEXT MONth on the 14th. So, unless the methotrexate works better I'll be on this Prednisone another month. How does that help? Ya learn something every day.....

sarah

Can your doctor do an override? Insurance companies almost always refuse at first, the doctor does an override and then you get what you need. They do this stupid dance all the time. Call your doctor back and ask them for the override.

Hey thanks, she's going to call me back in a little while (I hope!) and I'll ask! Super,

Sarah

Great idea Deanna! My doc does over rides too. In the mean time...stay on that pred! It is taking away that inflammation that is causing pain and damage. Don't ya just love insurance? I just got a letter from mine stating they would
not longer cover my Nexium. All the others give me bad headaches. They
will make no exceptions. So, I guess now I have a choice, heartburn or
headaches.Check into the drug company that makes it. Alot of times as long as there is no generic they have an assistance program. My insurance said no to Enbrel after a year with MTX but a call from my Dr got things going. I sure hope your insurance will pay for an infusion.

Success!! They just called and I have a Thursday appointment,

thanks for the encouragement, Sarah

Something else to keep in mind....in many cases we, as an employee, are covered by an employer that is "self-insured". In simple terms, your doctor or pharmacy bills an insurance company, the insurance company writes the check, but the insurance company is then reimbursed by your employer.

So, in some cases, your employer's Benefits Manager at work can also be involved in approving an over-ride. Again, in simple terms, a doctor would request an over-ride of the standard coverage to the staff pharmacist at the pharmacy benefit managing company (i.e. like a Caremark, etc.), then the pharmacy benefit manager (i.e. Caremark) would explain the unusual circumstance to the employer's Benefits Manager and request approval. When the employer determines which drugs will be covered, some drugs are set up as requiring an "over-ride" in some circumstances.

In rare circumstances, an appeal can also be filed with an employer's Benefit Trust Committee.

Hope this helps.