Question about biologics

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nev
Regular Member


Date Joined Feb 2007
Total Posts : 122
   Posted 5/5/2008 7:01 AM (GMT -7)   
So I was wondering how many of you were approved for biologics by your insurance company, but did NOT have a positive RF or other positive test?
 
thanks guys,
nev 

Trying2BFree
Regular Member


Date Joined Oct 2005
Total Posts : 251
   Posted 5/5/2008 8:02 AM (GMT -7)   
Yes, I was on Remicade for a year and now Orencia.  I've never had a positive RF or CCP.

Jeannie 
SLE diagnosis 10/05 now changed to RA 3/06, Endometriosis 5/05, PCOS 1990
Meds: Metformin ER 1500mg (PCOS); Loestrin BCPs (Endo); Methotrexate 15mg (RA); Metanx 5mg (RA); Orencia 750mgs (RA); Lunesta 2mg (as needed); Prevacid


momto3
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Date Joined Nov 2006
Total Posts : 1331
   Posted 5/5/2008 8:30 AM (GMT -7)   
My insurance company approved me for my Enbrel and I have never tested postive for any of the RF, Sed rates etc.

nev
Regular Member


Date Joined Feb 2007
Total Posts : 122
   Posted 5/9/2008 11:20 AM (GMT -7)   
So my insurance did turn down the humira and told doc to choose a less expensive drug. They called in another injectable and it starts with a Z. Can't remember what it was called, but my share to pay would be around $350, which I can't afford. So I called my doc to ask if there is anything with a regular copay/generic he could prescribe. Haven't heard back in 24 hours.

I do have an elevated sed rate and another inflammation (a chemistry test, cant remember name) test that is elevated.

What do you guys think? Every ins is different, currently I have BCBS Alliance Choice.

thanks,
nev

momto3
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Date Joined Nov 2006
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   Posted 5/9/2008 11:53 AM (GMT -7)   
Have you tried the methotrexate and plaquenil already? if not that could be why? I'm not sure what starts with a Z? but then there are so many meds now...For me, I have been on the plaquenil for over a year and the methotrexate, tried all of the NSAIDs, and now going on three years later I am finally moving on to the Enbrel. I know that Methotrexate is also an injectable? but I'm not sure of the other name it goes by..sorry!
 
Insurance companies can be so frustrating and some of these meds are so expensive...my insurance company haggles over the cost of Lunesta for crying out loud! It can get pretty ridiculous I know!

nev
Regular Member


Date Joined Feb 2007
Total Posts : 122
   Posted 5/9/2008 1:40 PM (GMT -7)   
I have been on prednisone since November 07 and 2.5mg oral methotrexate since the first of the year.

I've been "unofficially" diagnosed with fibromyalgia for ins purposes. So I'm present a bit over on the fibro board. Also I have a friend from high school that turned mentally ill and have turned to the bipolar board for support. So I've been around, but the whole Arthritis/Rheumatology deal is new. I know next to nothing about the common meds so here I am.

But then my blood tests showed inflammation late last year, I was excited to have a concrete reason for the way I have been feeling for the last 13 years.

The pred. and methotrexate have helped moderately, I can do a bit more each day than I used to be able to. Am eager to get off the prednisone as it caused the start of facial hair growth(slight but horrifying). I'm now at 5mg of prednisone from 10. My doc wants to see me doing substantially better which is why he's moving to add biologics.

Are there any other options?

-nev

momto3
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Date Joined Nov 2006
Total Posts : 1331
   Posted 5/9/2008 2:19 PM (GMT -7)   

Well Plaquenil is an option and many of us here have used it or are on it currently...do you just take one 2.5 a week? How many of the MTX pills do you take per week? I agree too much pred is never a good idea, and yet it works wonders!! That is how I ended up on the Enbrel because my doctor says that was an indication that I needed it since I did so well on the prednisone. I've been taking 8 pills at 2.5 mg of the MTX and it worked for awhile but then just stopped, and then I was able to move on to something else. I would take prednisone in a minute but my doctor is pretty stingy with it because of side effects. That is the only medication that gets rid of pain/inflammation completely and within a few hours for me..

My diagnosis is poly inflammatory unspecified whatever that means!! Do you take meds for fibro then? I'm surprised if you actually have something showing inflammation you can't get covered for the medication. Sorry to hear you are having such a difficult time sad


nev
Regular Member


Date Joined Feb 2007
Total Posts : 122
   Posted 5/9/2008 6:40 PM (GMT -7)   
I take 6 2.5mg mtx pills a week.

For fibro symptoms I take Soma (muscle relaxer that doesn't put me to sleep). My fatigue is quite bad and tried Provigil. But I only take it if I really need it, due to side effects, feeling jittery mainly. Also taking it for 1 day doesn't take a day or two to feel better. I also take prozac-somewhat related.

I've tried many different supplements.

I have recently tried Tramadol and Vicodin for pain. It helps me be more physically active, but I can't rely on pain killers for obvious reasons. I can't take them everyday/forever.

I also had a VERY low Vit D3 level and take 50,000IU a month.

There are other meds and problems I have, like TMJ disorder.

I think that answers your question, thanks for getting back to me, the responses are helpful.

-nev

erin.K
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Date Joined Mar 2005
Total Posts : 3148
   Posted 5/11/2008 10:59 PM (GMT -7)   
oh geesh nev!
you need help & bad!
oh boy lemme' see....usually w/ autoimmune diseases you'll go through "the ladder" of meds.  they exhaust all nsaids & cox2's & prednisone and then move on to plaquenil.
methotrexate is next & you can get that in an injectable definitely. it may work better than the oral form!
i'd ask the doc about that.
 
i did have the +RF in my labs and an sedrate.
you do see a rheumatologist right? and the diagnosis HAS to be "rheumatoid arthritis" or "psoriatic arthritis" in order to be approved.  some insurances will not approve a drug that is not within the scope of practice of say a General Doctor or PCP or family practice MD.
 
so perhaps the rheummy can RX injections of MTX.
can you get to a specialized Hospital for Bone & Joint Diseases?
 
then you'd move onto say the biologic Enbrel (some take MTX along with Enbrel too).  it's a weird High Tier drug that may need prior authorization in order to be approved by the insurance co.
Humira is TNF biologic injectable...it's $$$$$$$ too.
(both enbrel & humira have financial aid!!!!!!!! you enroll & Humira sends the meds to your door step at NO COST if you qualify, or it picks up a chunk of money where ins. does not pay).
 
Remicade you go to the hospital for an IV...i'm on that now, and it's covered by Medicaid and Medicare D.
Rituxan & Orencia are similar biologics given IV...
 
most meds do need a fight to get approved.
 
i'm sure many more folks will add their input.  pretty much everyone's been through this to some degree.
 
do you at least have pain meds in the meantime?
 
hang in there! this too shall pass.
erin 
Arthritis Forum Moderator & Co-Pilot
Active Severe Rheumatory Arthritis. Crohns Disease. A.Chiari Malformation.
Meds: Remicade 600mg Q3weeks; 6MP; Avelox; Zolfran; Entocort; URSO Forte; Dilaudid; Oxycodone. 


yalinda
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Date Joined May 2006
Total Posts : 1179
   Posted 5/12/2008 12:05 AM (GMT -7)   
hey nev i too have a neg RA factor but my c reative protiens, sed rate, ana, and cbc were all elevated as well as xrays confirming joint synovium inflammation or depletion. i was on mtx and pred for a good year before i went on enbrel. i agree with erin enbrel has a great finace aid package that might not cost you much even if insurance wont sponser cost??? i would look into it with doc- plus i would ask doc to relook at pw he/she sent and reapply. you have the right to a fair hearing on any medical issues. for me enbrel has worked great. good luck yally

momto3
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Date Joined Nov 2006
Total Posts : 1331
   Posted 5/12/2008 7:23 AM (GMT -7)   
Erin brings up a good point, there is "financial aid" and this was mentioned to me if I didn't have my health insurance there are other ways to help pay for the cost of Enbrel.

Erin? Are you sure you have to have a diagnosis of RA to get the Enbrel? None of my tests have ever returned positve, and on my sheet that I always take to the front desk it says "poly inflammatory unspecified" and I find it so frustrating to be going there for three years without ever having some kind of formal diagnosis. When I was on the phone with the mail order nurse, she asked me what my diagnoses was and I just said joint inflammation. The rheumy has never said I have RA.
Sorry to hear you have to sit in the chair! When I went in for my first practice injection...like an idiot I asked what the chairs were for..and the nurse told me they were for the Remicade patients and she said lets hope you can avoid "the chair".

Anyway back to the finances, I think there are ways to get around it because even with insurance, they were willing to pay my copay but somehow it turned out to be less and wasn't needed. I think you should look into it more. Enbrel works for so many people, its worth a try.

nev
Regular Member


Date Joined Feb 2007
Total Posts : 122
   Posted 5/13/2008 12:37 PM (GMT -7)   
Thanks to each of you who replied, each of you have encouraged me and even made me laugh with the whole "avoid the chair" thing.  Too funny!
 
Humira didn't pan out, but Enbrel did.  Gave myself the first injection yesterday.  I called the doc and said please try something else for me I can't afford the $360 copay.  Then they told me about the $325 help from the drug Co.  So I'm trying it.
 
Is it just me or did the medicine give me an energy kick, less pain and lower fatigue?  Could be placebo effect, or even a good day (very few good days usually).  Any of you have this happen?   I am SOOO not complaining!
 
I am seeing a Rheumy.  I am very happy with him.  When I mark my pain and fatigue scale for him, he doesn't question it.  I look happy and healthy, I'm only 31, but feel like a rotten 80 year old.
 
-nev

momto3
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Date Joined Nov 2006
Total Posts : 1331
   Posted 5/13/2008 4:00 PM (GMT -7)   

I'm happy to hear it work so well for you, I have almost finished my entire order of a 3 months supply and have not had that good of results.  My first injection was at the office by the nurse and now several weeks later and a few starts and stops, I feel better but it tends to run out about halfway through the week.  I feel pretty much the same minus some of my hip pain..if I get sick or something nothing helps not even the Enbrel.  Hopefully going to twice a week will help even more.

 

Congrats on your success! Let us know how it goes for you :)


nev
Regular Member


Date Joined Feb 2007
Total Posts : 122
   Posted 5/14/2008 6:30 AM (GMT -7)   
momto3- I do hope the twice a week works for you. Does that make your copay higher or not? Just wondering.

-nev

momto3
Veteran Member


Date Joined Nov 2006
Total Posts : 1331
   Posted 5/14/2008 6:58 AM (GMT -7)   
Hi there,
 
I'm not really sure, I paid $40 for a three month supply of the 50mg injections (sub q's).  I doubt it since it is availabe in both 25 and 50..and for our insurance $40 is considered a top tier copay so we really can't go any higher for a copay. We have, 20, 30, and 40.
 
Thanks! I hope it works too, my body seems to be really stubborn when it comes to these kind of things and I really don't want to visit "the chair" tongue

erin.K
Veteran Member


Date Joined Mar 2005
Total Posts : 3148
   Posted 5/14/2008 8:02 PM (GMT -7)   
you're right momto3, i should have explained myself better...i was just singling out PsA & RA to use as examples.
 
nev...i used to get souped up too!  but hey, ya' take what you can get! i truly wish you well with the Enbrel.
 
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