Need help now- insurance company fight UPDATE

New Topic Post Reply Printable Version
[ << Previous Thread | Next Thread >> ]

junerainbow
Regular Member


Date Joined Feb 2010
Total Posts : 403
   Posted 7/28/2010 2:30 PM (GMT -7)   
My doctor decided to join the mayo's treatment plan but now my insurance company is denying me the use of methotrexate unless I take humira or remicade with it.

Has anyone heard of this? My doctors are flabbergasted. They don't understand. If I can't get the methotrexate, which is better.. humira or remicade...

I am in tears... this is so ridiculous.
40 yo...mom to three wonderful kids, and wife to an amazing , supportive husband of 18 years..
-----------------------------------------------------------------------------------------------------------------
Diagnosed with gluten intolerance April 2009

Diagnosed with Crohn's March 2010- Mayo Confirmed May 2010
Back on Prednisone, Colestipol.Nexium, Propranolol, Vivelle patch
No longer on Imuran due to pancreatitis
Have taken Entocort, Bentyl, Flagyl, Lomidil, Pentasa
Have had myriad of health problems attributed to many different things over the past ten years. Our family has a history of Crohn's, Ulcerative Colitis and Bowel Cancer.

Post Edited (junerainbow) : 7/29/2010 4:38:10 PM (GMT-6)


njmom
Veteran Member


Date Joined Apr 2006
Total Posts : 1884
   Posted 7/28/2010 2:48 PM (GMT -7)   
Maybe the link below will help. If I find anything else, will send your way.
 
It says, "Although both methotrexate and infliximab (Remicade) are known to be effective against Crohn's disease, combining them provides no extra benefit, a researcher said here...

Gary Lichtenstein, M.D., of the University of Pennsylvania in Philadelphia, commented that the findings were no surprise. Earlier studies in his own lab and elsewhere had suggested that combinations of drugs do not add benefit to individual biologic therapies in Crohn's disease, he said. "In most patients you don't need to add anything. These biologic agents are wonderful drugs by themselves. By adding drugs such as methotrexate or steroids you are just increasing the risk of serious adverse events," he said."

DDW: Methotrexate Adds No Benefit to Infliximab (Remicade) in Crohn's Disease http://www.medpagetoday.com/MeetingCoverage/DDW/9598

Post Edited (njmom) : 7/28/2010 4:07:42 PM (GMT-6)


njmom
Veteran Member


Date Joined Apr 2006
Total Posts : 1884
   Posted 7/28/2010 3:15 PM (GMT -7)   
Btw, I think you will win the fight against the insurance company. I noticed you had pancreatitis due to Humira, so that is a risk factor for you they can't ignore.
 
They don't have a leg to stand on, from the standpoint of written therapeutic guidelines for Crohn's ...The insurance company might be going by guidelines more appropriate for arthritis than Crohn's.
 
If you are following a Mayo protocol, who are they to disagree with the top Crohn's docs in the country?
 

junerainbow
Regular Member


Date Joined Feb 2010
Total Posts : 403
   Posted 7/28/2010 3:16 PM (GMT -7)   
thank you for the link..

I really don't understand.. and i keep crying ... darn it..why do insurance companies get to make decisions..they haven't even seen me. What would be the reasoning of forcing me to be on both methotrexate and humira. Now my doctor called and wants me to reconsider just going on humira or remicade. He does not want me on two meds..I have such horrible reactions he just wants to do one at a time.

I am stunned.
40 yo...mom to three wonderful kids, and wife to an amazing , supportive husband of 18 years..
-----------------------------------------------------------------------------------------------------------------
Diagnosed with gluten intolerance April 2009

Diagnosed with Crohn's March 2010- Mayo Confirmed May 2010
Back on Prednisone, Colestipol.Nexium, Propranolol, Vivelle patch
No longer on Imuran due to pancreatitis
Have taken Entocort, Bentyl, Flagyl, Lomidil, Pentasa
Have had myriad of health problems attributed to many different things over the past ten years. Our family has a history of Crohn's, Ulcerative Colitis and Bowel Cancer.


njmom
Veteran Member


Date Joined Apr 2006
Total Posts : 1884
   Posted 7/28/2010 4:05 PM (GMT -7)   
My guess is they think the combo might be more effective than just one med, alone. My other guess is they are just looking for an excuse to deny you.
 
Their decision needs to be based on mainstream medical science - clinical trials showing evidence that combos are definitely better than meth, alone. I haven't been able to find any research that shows clear evidence, from a clinical trial, that a combo of meth-humira or meth-remicade is better than meth alone.     
 
As the article showed, at one time, for instance in 2006, there were top docs who thought methotrexate mixed with remicade might be more effective than just one of them, alone. But the research presented in 2008 let the medical profession know this combo is not more effective, at least not for Crohn's. 
 
Have you called the insurance company and asked it how to appeal the decision?
 

junerainbow
Regular Member


Date Joined Feb 2010
Total Posts : 403
   Posted 7/28/2010 4:12 PM (GMT -7)   
They are closed for today so first thing in the morning I will be calling. And I will be appealing. Thank you for all your input.. I appreciate your hard work..
40 yo...mom to three wonderful kids, and wife to an amazing , supportive husband of 18 years..
-----------------------------------------------------------------------------------------------------------------
Diagnosed with gluten intolerance April 2009

Diagnosed with Crohn's March 2010- Mayo Confirmed May 2010
Back on Prednisone, Colestipol.Nexium, Propranolol, Vivelle patch
No longer on Imuran due to pancreatitis
Have taken Entocort, Bentyl, Flagyl, Lomidil, Pentasa
Have had myriad of health problems attributed to many different things over the past ten years. Our family has a history of Crohn's, Ulcerative Colitis and Bowel Cancer.


grumpygi
Regular Member


Date Joined May 2010
Total Posts : 266
   Posted 7/28/2010 7:46 PM (GMT -7)   
June: Sigh . . .its a sigh of sympathy . . . that you don't feel good and have layers of issues stacking up on you. Have you ever thought about calling your congressman? Seriously, that is what they are there for - you hired him/her by voting them into office and they interface the government and resources in the community. Soooo when the congressman's office calls, businesses sit up and pay attention- even wayward insurance companies. Granted they have no legal right to force a response - ie like the police and a lawbreaker. But the political will weights heavily and insurance companies are restricted to state boundaries for a reason (to be supervised by the state). So I say go for it, call and make an appointment. What can it hurt? They don't charge you and can give you some great advice.
Meds: Celebrex, Omeprazole, Liadla, Entocort EC 9mg/day, Vit D, Mulitvit, Omega 3's, Ambian, Neurontin.
 
 
 


Tara28
Regular Member


Date Joined Apr 2005
Total Posts : 362
   Posted 7/28/2010 8:40 PM (GMT -7)   
I think njmom is right on. The insurance co is looking at info they have pertaining to RA patients...

I was on Humira earlier this year, and a Humira csr told me while it wasn't quite "off label", it was considered still an experimental treatment with only anecdotal results in CD. The major testing was done with RA. My gastro also said humira was more likely to be denied than remicade for crohn's for the same reason..

so my guess is they're using info that just isn't relevant to your situation. Don't sweat it, and do all possibe to appeal it and show them that what they''re proposing is ridiculous. I have never heard of ANYONE taking metho with humira- imuran, but not methotrexate.

Good luck!
33 years old, dx with Crohn's in 1998. Currently on :
Clofazimine 100mg daily,
Rifampin 600mg daily, and Clarithromycin 2 tabs daily
and Cipralex 10mg/day for anxiety.
Hydroxyzine, percocet, Ativan as needed.
5g pharmaceutical grade Omega 3's, 1000IU's Vitamin D3 daily
2 Perianal fistulas, and 1 more suspected. Crohn's only at end of colon, cecum. Remi, Asacol, Salofalk, Imuran, Humira did nada. Built immunity to long-term Cipro use, which also induced panic attacks.


Tara28
Regular Member


Date Joined Apr 2005
Total Posts : 362
   Posted 7/28/2010 8:47 PM (GMT -7)   
From humira's own website:

HUMIRA and Methotrexate: A Proven Combination

Many doctors prescribe HUMIRA to patients with moderate to severe RA who are already taking methotrexate. In clinical trials, patients taking HUMIRA and methotrexate saw better results than those taking methotrexate alone. In a study of patients with early, moderate to severe RA (diagnosed for less than 3 years, not previously treated with methotrexate), combining HUMIRA and methotrexate showed:

  • Almost 2 out of 3 people had no further joint damage at 1 year (compared to 37% taking methotrexate alone).
  • It was an average of 5 times more effective at slowing the progression of joint damage than methotrexate at 2 years.

Medications used to treat RA can have serious side effects. Make sure to tell your doctor about all the medications you're taking

 

Yet, in the crohn's section, not a drop of info about methotrexate...

 

This is the problem when Joe Blow Schmo (insurance)attempts to make medical decision s

I get this with disability ..they don't have 2 clues what's going on..


33 years old, dx with Crohn's in 1998. Currently on :
Clofazimine 100mg daily,
Rifampin 600mg daily, and Clarithromycin 2 tabs daily
and Cipralex 10mg/day for anxiety.
Hydroxyzine, percocet, Ativan as needed.
5g pharmaceutical grade Omega 3's, 1000IU's Vitamin D3 daily
2 Perianal fistulas, and 1 more suspected. Crohn's only at end of colon, cecum. Remi, Asacol, Salofalk, Imuran, Humira did nada. Built immunity to long-term Cipro use, which also induced panic attacks.


junerainbow
Regular Member


Date Joined Feb 2010
Total Posts : 403
   Posted 7/28/2010 8:50 PM (GMT -7)   
Thank you so much!!!!!!
40 yo...mom to three wonderful kids, and wife to an amazing , supportive husband of 18 years..
-----------------------------------------------------------------------------------------------------------------
Diagnosed with gluten intolerance April 2009

Diagnosed with Crohn's March 2010- Mayo Confirmed May 2010
Back on Prednisone, Colestipol.Nexium, Propranolol, Vivelle patch
No longer on Imuran due to pancreatitis
Have taken Entocort, Bentyl, Flagyl, Lomidil, Pentasa
Have had myriad of health problems attributed to many different things over the past ten years. Our family has a history of Crohn's, Ulcerative Colitis and Bowel Cancer.


tsitodawg
Veteran Member


Date Joined Sep 2006
Total Posts : 845
   Posted 7/28/2010 11:24 PM (GMT -7)   
about 3 years ago I was placed on methotrexate and remicade at the same time to help counteract the antibody buildup that was developing. It was a very effective combination for both the crohn's disease symptoms and the arthritis. It was considered pretty common practice around my area and on here there were multiple people doing the same thing. I would still be on the same regime but the methotrexate began messing with my liver levels and I had to come off of it. It is also pretty common practice to mix mercaptapurine with remicade or humira after you have been on the medication for a while. Has your doctor worked much with tnf inhibitor meds in the past? It is kinda funny that your insurance is requiring you to go on Remicade or humira first considering the cost difference to methtrexate. Methotrexate is not even 10% of the cost of my monthly remicade infusion.

GDen
Veteran Member


Date Joined May 2009
Total Posts : 703
   Posted 7/28/2010 11:40 PM (GMT -7)   
There was a big article in NEJM a month or so ago that showed combo therapies are more effective than mono therapies. I can't remember if methotrexate was mentioned.
Cimzia, Asacol


junerainbow
Regular Member


Date Joined Feb 2010
Total Posts : 403
   Posted 7/29/2010 5:50 AM (GMT -7)   
They are requiring me to do both at the same time. The Mayo wants me to just do the methotrexate alone. My insurance company is requiring that I add Humira or Remicade to the treatment plan before they will pay for the methotrexate. It sounds crazy to me. I did so much research yesterday and last night.. I was finding articles both ways..including the one mentioned here.. that remicade and metho were not needed together... I am confused. They open in ten minutes and now I don't know what to do.. just go with the remicade and metho and see what happens?
40 yo...mom to three wonderful kids, and wife to an amazing , supportive husband of 18 years..
-----------------------------------------------------------------------------------------------------------------
Diagnosed with gluten intolerance April 2009

Diagnosed with Crohn's March 2010- Mayo Confirmed May 2010
Back on Prednisone, Colestipol.Nexium, Propranolol, Vivelle patch
No longer on Imuran due to pancreatitis
Have taken Entocort, Bentyl, Flagyl, Lomidil, Pentasa
Have had myriad of health problems attributed to many different things over the past ten years. Our family has a history of Crohn's, Ulcerative Colitis and Bowel Cancer.


njmom
Veteran Member


Date Joined Apr 2006
Total Posts : 1884
   Posted 7/29/2010 6:04 AM (GMT -7)   
The article GDen refers to does NOT talk about combo therapy using methotrexate with another med, so it does NOT apply to your case. 
 
Instead, it talks about a clinical trial showing combination therapy using two other meds - infliximab (otherwise known as Remicade) plus azathioprine (Imuran). The article was published in April and  is here: http://www.nejm.org/doi/full/10.1056/NEJMoa0904492
 
Junerainbow, the most recent article I saw about the Remicade and methotrexate combo was published in 2008 and carries weight because it was formally presented at Digestive Disease Week. Articles published earlier than that speculated the combo might be more effective, but the 2008 findings put these speculations to rest. Have you seen more recent articles suggesting the combo of meth/Remicade is more effective than methotrexate, alone, for Crohn's?
 
It sounds like you are seeing conflicting stories on the web, so perhaps you can post links to the articles on this thread for us to take a look at?

Post Edited (njmom) : 7/29/2010 7:18:18 AM (GMT-6)


ZenaWP
Veteran Member


Date Joined Aug 2007
Total Posts : 884
   Posted 7/29/2010 6:47 AM (GMT -7)   

From past experience, the insuranace companies don't really seem to care what your doctor says unless you just continue and continue to fight them.  They intentionally deny things because a lot of people just give in then and the insurance company gets out of paying.  I can't understand why they would require you to take 2 meds, when it would cost them a lot more, and it does seem like they are going more off of arthritis guidelines than Crohn's.  I know I've had to fight them on several occasions and it took a long time and a lot of doctor's justification.  Even then, their panel of "doctors" tried to say whatever my GI said was not correct.  We eventually won out, but it took a lot of paperwork and time. 

I don't remember the mtx costing much even at full price when I was taking it.  Can you not buy it on your own without going through insurance?


Crohn's Disease with Arthritis, Non-Erosive Reflux Disease, Gastritis, Hashimoto's Thyroiditis, Endometriosis, Depression/Anxiety 


junerainbow
Regular Member


Date Joined Feb 2010
Total Posts : 403
   Posted 7/29/2010 6:52 AM (GMT -7)   
I will check into it.. I thought the doctor said it was expensive...but thank you.. and I agree.. why pay for two when you can just pay for one.... I hate that they make you fight.. our insurance premiums are so expensive..and who are they to make decisions...really frustrated.
40 yo...mom to three wonderful kids, and wife to an amazing , supportive husband of 18 years..
-----------------------------------------------------------------------------------------------------------------
Diagnosed with gluten intolerance April 2009

Diagnosed with Crohn's March 2010- Mayo Confirmed May 2010
Back on Prednisone, Colestipol.Nexium, Propranolol, Vivelle patch
No longer on Imuran due to pancreatitis
Have taken Entocort, Bentyl, Flagyl, Lomidil, Pentasa
Have had myriad of health problems attributed to many different things over the past ten years. Our family has a history of Crohn's, Ulcerative Colitis and Bowel Cancer.


junerainbow
Regular Member


Date Joined Feb 2010
Total Posts : 403
   Posted 7/29/2010 3:37 PM (GMT -7)   
After a long day of talking to everyone in the insurance company, it looks like we have approval... YAY... the weird thing is that if we go to a private pharmacy it will be half the cost.. if we use the specialty pharmacy the insurance wants us to use, it will be way more expensive. For some reason the insurance company itself was confused over the "specialty drug" methotrexate but once that got sorted out, everything fell into place. Or so I hope. Tomorrow we are supposed to get the details of the pharmacy in town and when we start injections.

Ok Breathing... I am hoping that this does work for me. thank you , thank you .. so much. We used all the articles and made sure we educated the insurance company and it seemed to be effective.

thank you!!!!!
40 yo...mom to three wonderful kids, and wife to an amazing , supportive husband of 18 years..
-----------------------------------------------------------------------------------------------------------------
Diagnosed with gluten intolerance April 2009

Diagnosed with Crohn's March 2010- Mayo Confirmed May 2010
Back on Prednisone, Colestipol.Nexium, Propranolol, Vivelle patch
No longer on Imuran due to pancreatitis
Have taken Entocort, Bentyl, Flagyl, Lomidil, Pentasa
Have had myriad of health problems attributed to many different things over the past ten years. Our family has a history of Crohn's, Ulcerative Colitis and Bowel Cancer.


ivy6
Elite Member


Date Joined Sep 2005
Total Posts : 10404
   Posted 7/29/2010 3:47 PM (GMT -7)   
I'm glad things seem to be working out, June.
Co-Moderator Crohn's Forum.

Medications for Crohn's ~~ Diet and Nutritional Therapy for Crohn's ~~ Dealing with Abscesses and Fistulae ~~


Tara28
Regular Member


Date Joined Apr 2005
Total Posts : 362
   Posted 7/29/2010 8:01 PM (GMT -7)   
yay! Good for you! :-)
33 years old, dx with Crohn's in 1998. Currently on :
Clofazimine 100mg daily,
Rifampin 600mg daily, and Clarithromycin 2 tabs daily
and Cipralex 10mg/day for anxiety.
Hydroxyzine, percocet, Ativan as needed.
5g pharmaceutical grade Omega 3's, 1000IU's Vitamin D3 daily
2 Perianal fistulas, and 1 more suspected. Crohn's only at end of colon, cecum. Remi, Asacol, Salofalk, Imuran, Humira did nada. Built immunity to long-term Cipro use, which also induced panic attacks.


njmom
Veteran Member


Date Joined Apr 2006
Total Posts : 1884
   Posted 7/29/2010 8:43 PM (GMT -7)   
Victory is sweet, isn't it? Congrats and good luck with the new med! 

MMMNAVY
Veteran Member


Date Joined Jul 2006
Total Posts : 6927
   Posted 7/29/2010 8:54 PM (GMT -7)   
June,
I am sorry I did not see this earlier. MTX cost's around 15 bucks (or less) a week (and has been around for alot longer then either remi or humira), both of those other meds cost several thousand. This is just insane that they would do that to you.
Hugs,
Navy
Forum Co-moderator - Crohn's Disease/Thyroid Disorders:_All comments have the caveat contact your local health care provider.

I will find a way or make one. –Phillip Sidney 1554-1586

All that I am and all that I shall ever be, I owe to my Angel Mother.

The Bucket List- Have you found joy in your life?  Has your life brought joy to others?

Make sure your suffering has meaning…


Cyborg Ninja
Veteran Member


Date Joined Jan 2006
Total Posts : 660
   Posted 7/29/2010 8:57 PM (GMT -7)   
This has to be the most disturbing violation of medical procedure I have ever heard of from an insurance company. Forcing a patient to take a combination of medications as risky as these drugs is so incredibly awful that I just can't express my feelings here without violating policy on profanity. I would absolutely love to speak to your insurance company. If you can tell me what company it is (Humana is within my town, btw), I absolutely WILL speak with them. Even though your problem is solved, there may be other people who are still being forced to do this and are risking their lives because of it!
Current DX: Graves' disease, Crohn's disease, gallstones, scoliosis, syringomyelia


grumpygi
Regular Member


Date Joined May 2010
Total Posts : 266
   Posted 7/30/2010 5:58 AM (GMT -7)   
june:  you got some great directions and supportive literature.  There are usually ways around road blocks and impediments that people throw up.  I never really understand why the hoops have to be jumped through, its kinda like groundhog day where you keep doing the same thing over and over, trying to modify one small thing to acheive the desired outcome. So congratulations on sticking to you guns!  Victory is sweet!  Hope you feel better soon. 
Meds: Celebrex, Omeprazole, Liadla, Entocort EC 9mg/day, Vit D, Mulitvit, Omega 3's, Ambian, Neurontin.
 
 
 


junerainbow
Regular Member


Date Joined Feb 2010
Total Posts : 403
   Posted 7/30/2010 9:11 AM (GMT -7)   
I partied too soon... still another approval and it won't come until monday... another weekend of waiting to see if there is an answer... I do hope the approval comes and we can finally move...geesh... just when you think you clear the hoops there is another one around the corner...

i have blue cross blue shield and not really enjoying them.

I am moody.. the 50mg of prednisone is not working.. i am so sick.. and my joints hurt so bad, and I am crying.. I don't know why.. I just want a final answer.. or its the steroids or its both..I am just tired...and just want to feel better.
40 yo...mom to three wonderful kids, and wife to an amazing , supportive husband of 18 years..
-----------------------------------------------------------------------------------------------------------------
Diagnosed with gluten intolerance April 2009

Diagnosed with Crohn's March 2010- Mayo Confirmed May 2010
Back on Prednisone, Colestipol.Nexium, Propranolol, Vivelle patch
No longer on Imuran due to pancreatitis
Have taken Entocort, Bentyl, Flagyl, Lomidil, Pentasa
Have had myriad of health problems attributed to many different things over the past ten years. Our family has a history of Crohn's, Ulcerative Colitis and Bowel Cancer.


njmom
Veteran Member


Date Joined Apr 2006
Total Posts : 1884
   Posted 7/30/2010 4:07 PM (GMT -7)   
You have the docs and evidence on your side, so it should be fine. Will keep my fingers crossed!
New Topic Post Reply Printable Version
Forum Information
Currently it is Saturday, December 10, 2016 5:34 PM (GMT -7)
There are a total of 2,736,123 posts in 301,354 threads.
View Active Threads


Who's Online
This forum has 151451 registered members. Please welcome our newest member, YoEve.
303 Guest(s), 11 Registered Member(s) are currently online.  Details
bluelyme, YoEve, tickcheckguy, Sarebear89, porkysgal, astroman, NiceGuyEddie, rocckyd, maddysmom2015, myrawens, julymorning


Follow HealingWell.com on Facebook  Follow HealingWell.com on Twitter  Follow HealingWell.com on Pinterest
Advertisement
Advertisement

©1996-2016 HealingWell.com LLC  All rights reserved.

Advertise | Privacy Policy & Disclaimer