Denied Humira

The insurance company denied my doc's request for Humira to close the fistula and control the CD.

The company that screens med requests say I should go on 6 MP first and then if it does not work for a period of a year then maybe Humira.

Both my CR and GI docs are attiment about the Humira treatment.

My GI doc brought my case up at a confrence and there was unanimous agreement on the Humira treatment.

Should I be afraid of the 6MP?

I'm disgusted.

I totally feel your pain on this issue. It is SO wrong that an insurance company has the right to overrule your doctor's request for you to go on a certain medication. Especially one that has such a good reputation of really helping people to feel better.

I don't think you should be afraid of 6mp. I'm on azathioprine (similar to 6mp) as well as Humira and have not had any noticeable bad side-effects. However, I don't think it's fair that you need to spend a year hoping that the 6mp works though. Keep fighting for the Humira. And good luck.

Really hope you start to feel better on the 6mp, and hope you can get the ins. company to approve Humira for you!

Well I got leukepenia from 6-mp which later went away. AUOTMATIC failure. Its def. Not something you want but you would be approved for humira. Sorry its pessimistic but Im just trying to be positive for ya

I was on 6-MP for close to a decade with no side effects. It really worked well for me. Sorry to hear about the Humira.

just had a discussion with my gi team today about imuran. The leukemia incidence is theoretical at best. .9% per 10,000 treatment years vs .4%per 10,000 treatment years in general population. Just to put that in perspective to the incidence of dysplasia converting to Colon cancer resulting from chronic inflammation. That is somewhere around 10% after 10 years in Crohns patients.

I am on Imuran as opposed to biologics because here in Canada we have free basic health insurance and they see no reason or benefit to treat me with newer, less proven methods that cost thousands per month vs well documented, safe and proven treatments that cost under $100/mo. If I was unable to process the Imuran/MP6 I would be moved to biologics as the next stage in management. But we start off with the more sensible approach first. Same kind of principal I use when fixing my car. If it wont turn over I try to boost it before having it towed to a garage for an engine rebuild.

These new drugs look great and I hope they prove to be a good 10 or 20 years from now. With Imuran they know how that will pan out as it has been widely used since the 70's.

The biggest drawback of 6mp that I see is that it typically takes 3 months to start working.
Did you check and see if they would approve Remicade?? It is kinda similar to Humira. My insurance company wouldn't approve a double dose of Humira until I tried Remicade, and it turned out to be the best thing that has happened so far. It's good for fistulas too.

I was denied Humira at first also. But I also had a severe reaction to remicade, and my Dr wrote a letter to the insurance company stating without this treatment option death was very likely. I think I did 6mp for a short period of time about 10 years ago. If I am thinking correctly my tongue became swollen. So hang in there. I have several small fistulas and now liver damage because of extended use of all kinds of meds for the past 37 years, causing portal hypertension.
Just remember...you are not alone.

Thanks for your support.

It's just that someone sitting in an office 3K miles away has the ability to control my destiny.

It pisses me off! I think these people should walk in the shoes of evert person the deny for whatever disese for a day.....then let's see if the bean counters feel.

Do you have an HMO or a PPO? This matters since with a PPO they can try to deny the medication and tell you that you have to follow a specific path, but they can't go against your doctors wishes in the end. You might have to take remicade instead of humira since it has been around longer and is the standard of care in biologics for crohns right now, but that is a good choice as well and most people take that first anyway. If they do deny you for remicade also, contact your state insurance commissioner and ask them if there is an independent review you can apply for where actual medical professionals who aren't connected to the insurance company in any way can decide if humira or remicade are the right choice for you...and their decision is legally binding (at least that is how California does it). You have to take the time to talk to someone or email someone in the commissioners office however, and don't stop trying until you are able to physically talk to someone you feel will know the answer. Also, use the website to research what process you can go through to appeal a decision from both inside and outside the insurance company in your state.

If it is an HMO I don't really know as much about how those work, but my understanding is they do have more control over treatment. However, I still believe you are able to appeal their decision.

When you talk to the insurance company make sure you tell them you are reporting this incident to your state insurance commissioner and then follow through. It seems trivial, but this can in fact help get what you want because with enough reports like this, the company gets investigated. Then they find thousands of "mistakes" that they get fined for. They want to keep the attention of investigators away from them, so use your leverage if you can.

Mike,
If you don't mind me asking - what insurance company are you dealing with. I just started 6mp 6 weeks ago and hope its working but if it doesnt, humira will be my next option. My dr preferred 6mp over humira because of its longer track-record.
Just curious which company.
Good luck.

Hi guys,

Saidinstouch.....thanks so much for this information.

I was informed by my company's insurance administrator that we a switching insurance companies on April 1.

Currently I have Healthnet and we are switching to Empire Blue Cross.

I have had Blue Cross in the past and they were far and away better than the bums at Healthnet.

I see my GI doc tomorrow and we'll discuss the possibility of 6MP. My CR doc wants the Humira or Remicade more than my GI doc wants it, for the fistula.

Maybe if two docs request the same biologic they will have more reason to approve it.

Again, thanks for everyone's concern. Mike