Crohn's Disease Forum » Treatment » Humira/Adalimumab » TWO Humira shots / Insurance (denial)


09-03-2008, 07:11 PM   #1
My Butt Hurts
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TWO Humira shots / Insurance (denial)

CRAP!!
You know that Humira worked SO well for me for 4 months.
It took me from 10 times a day running to the potty to 1 or 2, and then it gradually stopped working.
My GI doc recommended 2 shots every other week instead of 1, and I thought I got the call with approval yesterday. (Silly me - they left a reference number to call back with, I thought it was referral number.)
Well, I've been denied. The guy said Humira is not FDA approved for Crohn's in doses over 40 mg every 14 days. He's sending me a form to fight it, wich I'll try with my doctor's help, but I doubt it'll work.

Anyone else on TWO shots? What insurance do you have? Did you have to fight it?

Denied... that sux.
09-03-2008, 07:38 PM   #2
BWS1982
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Well that's the thing Pen, the FDA apparently thinks differently than your Canadian doc/nurse, from MBH's post, it sounds like 1 pen a week is the same as more than 40 every 2 weeks, but that's just what I'm gathering...
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09-03-2008, 07:43 PM   #3
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He said doses over 40 mg in 14 days aren't approved.
That would be the same (80 mg) whether it's 2 shots every other week or onr shot every week. It still adds up to 80 in 14 days.
I'll still try to fight it and see where it gets me.
There's still Remicade if the pred wears off. Maybe this will get me another 4 good months at least.
09-03-2008, 08:00 PM   #4
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HAAAAAAAAAAAA!!!
Pen, you are gettin' funnier!
09-03-2008, 09:24 PM   #5
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It is a REAL possibility you could get it approved. The fact that your insurance covers the drug at all is a good indication that with your Doctors office filling out the proper paperwork (and saying the right things) you can get approved for more doses. If it is a matter of studies I am sure your doctor can find a study or report of a patient (maybe from his own practice) that benefited from a double dose thus reducing overall insurance costs. You have to appeal to them financially But your doctor should be used to stuff like this. Just make sure to keep up to date with your doctors office on what they are doing to help you get approved for more doses. Good luck!
09-03-2008, 09:38 PM   #6
butt-eze
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I'd ask your doctor if he could provide you samples for those alternating weeks. I know that doctors can sign for samples of Humira. Even dermatologists get samples of Humira.
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09-03-2008, 11:13 PM   #7
BWS1982
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I remember my GP getting VERY upset when he started going off on the way money makes the medical world go 'round, I could tell he was pissed about his experiences, this was back in January when he put me on Metoprolol for rapid heart rate...he said that's why doctors would make poor use in the insurance world, because a true doc will only want to help, and that's not good for business. I agree.
09-19-2008, 02:41 AM   #8
saidinstouch
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Basically that is the FDA approved treatment to receive a therapeutic response that they have deemed safe which is all your insurance company is really obligated to cover under their policy. However, in cases of medical necessity as documented by your doctor most insurances will go ahead and give you a special dose approval for increased dose/frequency after initially denying it pending further information from your doctor. It's a really stupid system, but the policy of deny first pay later saves them millions of dollars just by holding the money even a few more days.

If your doctor documents the need for increased dose to continue to receive a therapeutic response, your company is reasonably compelled to honor your doctors wishes. They aren't legally bound to, but there are ways to force them to cover the medication at a higher dose. In California you can obtain an independent medical review through the department of insurance which essentially forces the insurance company to accept the decision of the insurance board rather than their own reviewers. I'm 99% sure every state will have a similar policy. In addition to this, you might suggest that remicade is another option your doctor is tossing around and that the cost of an infusion at a hospital is ~$25,000 ever 4-8 weeks (~$5000 at an infusion center) and the cost of 4 pens of humira is about $3600 a month. They don't always follow the cheapest path, but sometimes talking dollars and cents to them can help you.

Finally, call abbott for copay assistance. I was recently enrolled in this plan due to horrible coverage on my new insurance policy and it is fairly generous (though won't cover nearly the cost of an added set of pens at the rate they are covering me). They might have different tiers for different patients and this is a great option to explore.

All in all these options take a lot of time. Your best bet is to go into your doctors office and sit with the assistant who deals with prior authorizations and get them on the phone with the insurance company in your presence. Have them discuss exactly what has to be done to expedite the procedure. In general this works the best since there can be few excuses later. I've spent well over 100 hours keeping myself covered for Humira due to 3 insurance changes over the course of a year so I've dealt with all the avenues and these are your best bets. Ideally the company will look at the medical necessity and approve it, you just have to be persistent enough.
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Crohn's Disease Forum » Treatment » Humira/Adalimumab » TWO Humira shots / Insurance (denial)
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