Can't get weekly Humira approved

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Pibbin
Regular Member


Date Joined Apr 2008
Total Posts : 163
   Posted 5/23/2008 9:52 AM (GMT -7)   
Help! My insurance (UHC/Medco) just denied my appeal and won't pay for weekly Humira injections. Only for every other week, which hasn't been enough to get me into remission. My GI wrote a persuasive letter and everything.

Luckily, I've been able to get my hands on the extra Humira that I need from Abbott's Patient Assistance Program for the near future, but I am so angry at my insurance, and plan to keep appealing. Has anyone been through this -- any suggestions? My GI wants me to pursue legal action, he is so angry about it.
Dx Mild Proctitis 7/06 at age 33, Dx Severe Pan Colitis 5/07, Dx Crohn's Colitis 10/07
Failed Asacol, Lialda, 6-MP, Canasa, Rowasa, Entocort, and Remicade
On Humira since 1/08 with promising results, but can't get below 5mg Prednisone
Take Tylenol #3 as needed when not in close proximity to a bathroom.
Currently on 40mg Prednisone again since mid-March flare, ack
4/9/08 Humira dose increased to 40mg/week, Start slow Pred taper


sr5599
Veteran Member


Date Joined Aug 2007
Total Posts : 1202
   Posted 5/23/2008 10:55 AM (GMT -7)   
I was never able to get approval on weekly coverage. I went through two appeals (including the letter from my GI, as you did) and they wouldn't do it. I have Blue Cross/Blue Shield of OR. I did not take it to legal level. I had done weekly shots for a month and it was an improvement over bi-weekly, but still not remission. Maybe it was too short a time. But without coverage... I never thought to try going through Abbott!

Good luck! If you find a way to get approval, I'd like to know what convinced them!
 
Also, I wanted to say that there are others on here with coverage for weekly shots.  I don't want my post to be depressing!  Just commiserating!


--40 year old female, dx as UC in '04 (1st symptoms in '03), switched to Crohn's in '05, 1 fistula, crohn's colitis, limited to large intestine
--rejected (reaction/didn't work): Asacol, AZA, 6-MP, MTX, Remicade, Humira, prednisone
--stuck on methylprednisolone, tried Prochymal in Phase III study (can't wait til it's approved!)
--started Tysabri 3/21/08
--single mom to 10-year-old girl


ZenaWP
Veteran Member


Date Joined Aug 2007
Total Posts : 884
   Posted 5/23/2008 12:08 PM (GMT -7)   
My GI told me last week that he had one patient who ended up with severe kidney problems due to Remicade.  They tried and tried but insurance would not approve whatever treatment/medications he was requesting for the patient, even after multiple letters/requests/forms, whatever they do to appeal.  Finally, he said he had to talk to the director of the department that makes the medical decisions and say something to the effect of, "Look, you either pay for this treatment, or you will get to pay for dialysis and a kidney transplant."  He said only then did it sink in how badly this treatment was needed and then insurance covered it.  Your doctor may just need to talk to the highest level person he can get in touch with and put the two options out there: either they approve Humira once a week or they get to pay hospital bills for surgeries, stays, or whatever situation may apply to you.  Maybe then it will sink in how serious and expensive it can get without the Humira.     

...rejoice in our sufferings, because we know that suffering produces perseverence; perseverence, character; and character, hope.   Romans 5:3-4


Mike W
Regular Member


Date Joined Aug 2006
Total Posts : 89
   Posted 5/23/2008 4:21 PM (GMT -7)   
Gotta love insurance companies. No delays or hassle in them taking your premiums from you, I'm sure...
Diagnosed in 1999.
No surgeries.

Age : 31

Currently on 75mg 6mp , 20mg prednisone and probiotics.


Pibbin
Regular Member


Date Joined Apr 2008
Total Posts : 163
   Posted 5/23/2008 6:42 PM (GMT -7)   
LOL, don't you know it, they have absolutely NO problem taking my money.

Zena, thanks for your suggestion, I'm sure my dr will get more involved as needed. In the letter he wrote, he basically said Humira was my last chance at avoiding surgery... you'd think they would want to pay for prevention vs worst case scenario!

sr, thanks for confirming there are others on here getting weekly shots, I thought that might be the case.
Dx Mild Proctitis 7/06 at age 33, Dx Severe Pan Colitis 5/07, Dx Crohn's Colitis 10/07
Failed Asacol, Lialda, 6-MP, Canasa, Rowasa, Entocort, and Remicade
On Humira since 1/08 with promising results, but can't get below 5mg Prednisone
Take Tylenol #3 as needed when not in close proximity to a bathroom.
Currently on 40mg Prednisone again since mid-March flare, ack
4/9/08 Humira dose increased to 40mg/week, Start slow Pred taper


Crohn'snme
Veteran Member


Date Joined Feb 2007
Total Posts : 734
   Posted 5/23/2008 8:05 PM (GMT -7)   
Yikes, I am on Cobra for one month. My hubby just changed jobs and I switched from Remicade after 5 years to Humira. I know i need it more often, doesn't look promising. I would appeal it and be very strong and persisitant. I knwo when I went on Remicade I had to get a bit nasty. Unfortunatley I had to threaten lawyer action, they apprvoved it 5 years.

Mac_Gyver
Regular Member


Date Joined Aug 2007
Total Posts : 350
   Posted 5/24/2008 6:34 AM (GMT -7)   
I have United Health Care and fought for almost 2 months before it was finally approved unfortunately I was off HUMIRA the entire time waiting for approval that I could Not go back on. I started Tysabri now which strange enough as it is cost $3000 more a month to United health care than approving the weekly shots of HUMIRA would.
Symptoms Of Crohn's June of '06 (21 years old 285lbs). Colonoscopy in Jan '07 no sign of Crohn's.
Surgery for a Fistula in April '07, diagnosed suggestive Crohn's in May '07. August '07 small bowel follow
through, diagnosed with Crohn's (23 years old 180lbs). Off predisone and on tysabri 4/3/2008
============================================


Pibbin
Regular Member


Date Joined Apr 2008
Total Posts : 163
   Posted 5/24/2008 1:05 PM (GMT -7)   
Hey FinalMacGyver, do you have any secrets for how you got the Humira approved?

Sorry that you had to miss your meds during that time. These insurance companies are maddening -- the bottom dollar is more important than patient care. Hope Tysabri is working for you.
Dx Mild Proctitis 7/06 at age 33, Dx Severe Pan Colitis 5/07, Dx Crohn's Colitis 10/07
Failed Asacol, Lialda, 6-MP, Canasa, Rowasa, Entocort, and Remicade
On Humira since 1/08 with promising results, but can't get below 5mg Prednisone
Take Tylenol #3 as needed when not in close proximity to a bathroom.
Put back on 40mg Prednisone again during mid-March flare, ack
4/9/08 Humira dose increased to 40mg/week
Down to 15mg pred


Mac_Gyver
Regular Member


Date Joined Aug 2007
Total Posts : 350
   Posted 5/24/2008 2:15 PM (GMT -7)   
I sent in two appeals the second one I sent in I stated how much tysabri was a month, $8000, this was my next choice compared to Humira every week a month ='s $3,000. I think that put it into perspective for them. You said surgery may be you next choice write a letter comparing the cost of surgery, about $20,000 for the insurance company not including recovery to HUMIRA. Hope that helps. Good Luck
Symptoms Of Crohn's June of '06 (21 years old 285lbs). Colonoscopy in Jan '07 no sign of Crohn's.
Surgery for a Fistula in April '07, diagnosed suggestive Crohn's in May '07. August '07 small bowel follow
through, diagnosed with Crohn's (23 years old 180lbs). Off predisone and on tysabri 4/3/2008
============================================


elroque
Regular Member


Date Joined Apr 2008
Total Posts : 38
   Posted 5/26/2008 3:22 PM (GMT -7)   
I have BCBS of Texas and they also denied me for the Humira at 80mgs per week. After an appeal they finally approved it for 80mgs every other week for 5 years but denied the 80mgs weekly based on "the FDA's approved prescribing and safety information, clinical guidelines and uses that are considered reasonable, safe and effective". Niiiiiiiiiice-and that was after my poor GI kept going up to bat for me.
Rock
 
Love many, trust few, but always paddle your own canoe....


sr5599
Veteran Member


Date Joined Aug 2007
Total Posts : 1202
   Posted 5/26/2008 6:47 PM (GMT -7)   
Just to clarify, I am not actually using weekly shots. Since I was not approved for coverage, I am not using Humira at all. The out of pocket would have been to great to support the additional shots and bi-weekly was not effective enough to bother. But, from what I understand, needing weekly shots is not at all uncommon. I keep hoping the FDA will changing the prescribing dose and the insurance companies will be forced to cover it!
--40 year old female, dx as UC in '04 (1st symptoms in '03), switched to Crohn's in '05, 1 fistula, crohn's colitis, limited to large intestine
--rejected (reaction/didn't work): Asacol, AZA, 6-MP, MTX, Remicade, Humira, prednisone
--stuck on methylprednisolone, tried Prochymal in Phase III study (can't wait til it's approved!)
--started Tysabri 3/21/08
--single mom to 10-year-old girl


curley
Veteran Member


Date Joined Mar 2005
Total Posts : 4305
   Posted 5/26/2008 7:58 PM (GMT -7)   
I am as well taken Humira every week and did not have a problem wiith getting it approved for every week it may because that both my Rheumy and my GI went to bat for me and told them that it was crucial that I take it once a week because I have Crohns and RA,OA.I am glade that you are getting some help and I can sure understand why you are made at your insurance co.I do have an issue with my insurance becaus they did not wante to aprrove my pain patches because my Pain Doctor changed them from one patch every three day to every two and man they said no and my Rheumy faxed them the papers stating that I have RA and OAS not to mention Crohns and that it was very crucial that I put a new patch on every two days because my arthrits is in my is very active and in my spin.keep us up on your insurance.

Curley
.........
 


Pibbin
Regular Member


Date Joined Apr 2008
Total Posts : 163
   Posted 5/27/2008 7:29 AM (GMT -7)   
Thanks for all the responses -- I will try to stay hopeful. I am definitely going to re-appeal, even though I believe the denial letter from UHC said that there was no further appeal level possible. The weekly 40mg shots are definitely helping me -- I feel that I am soooo close to finally getting off the prednisone and getting into remission for the first time since diagnosis 2 years ago. Can't let the insurance company cut me off b/c they are only concerned with pinching pennies. The good news is that Abbott's Patient Assistance Program is providing me the additional shots while I am dealing with the insurance denial. I will keep you posted.
Dx Mild Proctitis 7/06 at age 33, Dx Severe Pan Colitis 5/07, Dx Crohn's Colitis 10/07
Failed Asacol, Lialda, 6-MP, Canasa, Rowasa, Entocort, and Remicade
On Humira since 1/08 with promising results, but can't get below 5mg Prednisone
Take Tylenol #3 as needed when not in close proximity to a bathroom.
Put back on 40mg Prednisone again during mid-March flare, ack
4/9/08 Humira dose increased to 40mg/week
Down to 15mg pred

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