Humira... I was denied coverage by Great West Life

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harbinson66
New Member


Date Joined Oct 2013
Total Posts : 6
   Posted 10/2/2013 6:27 AM (GMT -7)   
God I hate insurance companies.

I recently had a CT Scan and unfortunately it showed that my Crohn's is still active. My doctor begins talking about options and he asks me what I think about going on a "better class" of drugs.

Like, this is something I WOULDN'T want to do? What's the hold-up?

Errrr... well, it costs $30,000 a year.

Now, I work for the Canadian Medical Assoc., so everyone is fairly confident that I'll have insurance that will cover it.

Guess not.

So now I'm weighing my options. Do I divorce my wife and go on welfare so that she can at least keep our home, or do I simply wait for the rest of my digestive tract to dissolve to the point that I can no longer work and THEN divorce my wife so that my home-care requirements don't bankrupt our family.

How the hell does anyone pay for this drug?!

kazbern
Veteran Member


Date Joined May 2010
Total Posts : 8384
   Posted 10/2/2013 7:37 AM (GMT -7)   
I don't understand why a life insurance policy is providing you health care? Or maybe Great West Life is a health insuror? And doesn't the Canadian NHS provide your meds within its own plan?
*******************
50 yrs old, IBD diagnosis in spring '01. Proctitis, gastritis, ileitis.
Currently taking Pentasa (3g/day)generic Colazal (96 pills/day), Sulfazine (1.5 g/day), Prevacid, folic acid, vit. D (2K iu), flax seed oil (2 tsp/day), psyllium (1/2T daily), mesalamine enema as needed. Gluten free as of 5/30/11. Colonoscopy found no evidence of inflammation on 8/16/1

harbinson66
New Member


Date Joined Oct 2013
Total Posts : 6
   Posted 10/2/2013 7:41 AM (GMT -7)   
They also do health insurance... and by that I mean they'll cover your birth control or your prescription reading glasses but not much else.

I had to have a couple of molars replaced with dental implants. $3,000 each. They rejected my claim because my "molars" were considered to be "cosmetic".

I'm always getting compliments on how beautifully I chew food.

73monte
Veteran Member


Date Joined Mar 2007
Total Posts : 1775
   Posted 10/2/2013 9:27 AM (GMT -7)   

What Province are you living in?

If Ontario, you could apply to the Trillium fund. They will very likley cover the costs of Humira. Not sure, but I would think that there would be other organizations that would help cover the costs of this.

 

Tom.


harbinson66
New Member


Date Joined Oct 2013
Total Posts : 6
   Posted 10/2/2013 9:36 AM (GMT -7)   
I live in Ontario, but Trillium isn't going to help me. My 84 year old mother was denied Trillium because "she made too much money".

It sounds like Trillium is reserved for those who live below the poverty line.

I just got the news yesterday so you'll forgive me if I'm sounding negative and really bitter right now.

My doctor says that we can appeal and there may be other routes to go, but everyone (I was dealing with two nurses from Progress) seemed to think that I was a shoo-in for 100% coverage when I got the letter.

JaSanne
Veteran Member


Date Joined Oct 2006
Total Posts : 2082
   Posted 10/3/2013 5:01 PM (GMT -7)   
I know how you feel. My GI wanted me to go on Remicade back in the late '90s, but his nurse informed me that the total cost due to the infusion being done in the hospital was running $12,000 per infusion for their patients. I knew the insurance we had wouldn't pay and even if they did, my copay would have been more than our income anyway. That insurance company would purposely mistype codes just to throw the claims out. I had to fight for every single bill to be covered and it got old.

We had Great West later and it was a big step up from what we had, but I never did Remicade or any other biologics, for various reasons including financial.

I'm not the breadwinner, but my husband who's 60, is having his own medical issues and we're just praying we can keep things going. And we have an adult daughter who had to stop everything due to an even worse medical problem and has been totally dependent on us for five years. She had been independent before that and worked hard and she isn't on disability. So I know how you feel.
54 yr. old. Ileocolitis since early teens. Hemicolectomy-left side in 2001. Severe chronic pain due to spinal chord injury, rotator cuff injuries, enteropathic arthritis. History of endometriosis. Depression.

harbinson66
New Member


Date Joined Oct 2013
Total Posts : 6
   Posted 10/3/2013 8:34 PM (GMT -7)   
Well, surprising news today. It seems that when I got on a conference call with a nurse and the Insurance company they did a 180 and granted my application.

It's frustrating that they put us through hell for no apparent reason.

My wife (God bless her) is a pit-pull and she went to the HR department of our work and asked if Humira and Remicade were covered. They were... Okay, so then why was I being denied?

No explanation at all. Simply someone saying that a letter had gone out today overturning the initial rejection.

It just leaves me shaking my head.

For anyone who has been rejected, please fight it. I think they hope that you'll just go away.

I wish everyone here good health, and hopefully this will put me into remission.

Cheers, Jamie

73monte
Veteran Member


Date Joined Mar 2007
Total Posts : 1775
   Posted 10/4/2013 6:11 PM (GMT -7)   

That's great news Jamie!!!

Glad to hear that. I was going to suggest to keep insisting on coverage, whether via your insurance or Trillium. It's a shame that along with battling this dreaded disease, that we have to often fight so hard for appropriate care, treatment and in your case much needed coverage.

Tom.


harbinson66
New Member


Date Joined Oct 2013
Total Posts : 6
   Posted 10/4/2013 7:03 PM (GMT -7)   
They actually read this post (apparently they watch social media) and called me today to apologize for the way I was treated.

Now, while I'm grateful that they did that, it doesn't take away the fact that they put me through hell for a couple of days and I should have been covered all along.

Look, we all make mistakes but this isn't giving me change for a 10 when I gave you a 20; we're talking about people's lives here.

That's a hell of a mistake to make and as we all know, stress and Crohn's aren't exactly the best of friends.

They say that they are going to use this example as "teaching tool" for their staff in the future.

Well, if I can prevent someone else from going through it, then I guess it served a purpose.

It's nice to know that social media has the power to change things.

Now, lets just cross our fingers and hope that this stuff works. Maybe one day there will be a cure.

Hang in there everyone. We can beat this.

Jamie

Bane
Veteran Member


Date Joined May 2007
Total Posts : 589
   Posted 10/4/2013 10:32 PM (GMT -7)   
Darn, I was looking forward to ribbing a Canadian about inadequate health care systems- don't usually get a chance to do that!


On a serious note, glad it worked out. I hope you see some improvement on Humira. It seems to help me, somewhat. Keeps me alive, anyway, which is always good.
Diagnosed with Crohn's late December 2004. Getting by.

wombles
Regular Member


Date Joined Aug 2006
Total Posts : 21
   Posted 10/5/2013 7:43 PM (GMT -7)   
I feel so bad for you. In New Zealand, our health system is not perfect, but we do not have to have health insurance in order to get better medications. My husband has psoriatic arthritis and several other health issues. His medication list is; Humira, Leflunamide, prednisone, omeprazole, Lostaar, Atorvistatin, multivitamins, Aspirin, Codeine, Tramadol, Panadol and sleeping pills and more I can't think of. we pay $3 per item for 3 months supply of each. He has had multiple xrays, radioactive iodine, bone scan and CT this year at no cost too. It costs $17 to go to the Dr.If you ever get the chance to change the way your government thinks, this has to be better than missing out if you can't afford it.

mtooke
New Member


Date Joined Nov 2013
Total Posts : 1
   Posted 11/24/2013 2:47 PM (GMT -7)   
Hmm. I'm in the same situation with Great West Life over Remicade. I've been denied twice after initially being told that I was covered. I can't afford it and I don't qualify for Trillium. I'm at the point where my work is suffering and I barely have enough energy to take care of my kid at the end of the day.

After a bad scan this summer, my doctor suggested that a biologic (specifically Remicade) was the only thing that would work for my situation (fistulizing Crohn's).

After two+ weeks of waiting for paperwork, Great West called on Friday and said that I had been rejected for a second time because I hadn't yet proven that other, cheaper drugs (immuran - which my dr said was not at all appropriate for my situation) and prednisone (which I'm currently on, and is not a long term solution) hadn't failed me yet. So what do you do - wait another 6 months and put more chemicals into your body knowing that they will do nothing for you, hoping that Great West will actually make good on their initial claim?

Insurance companies are more concerned with the bottom line than they are with the health and well being of their policy holders. What gives them the right to override the decision of your health care provider? It's all very frustrating.

harbinson66
New Member


Date Joined Oct 2013
Total Posts : 6
   Posted 11/24/2013 3:05 PM (GMT -7)   
Try calling them directly. Speak to someone at Great West Life with your doctor or with a nurse from Remicade on the line with you. Best of luck!

Jamie

SupportiveMom
Regular Member


Date Joined Sep 2012
Total Posts : 259
   Posted 11/24/2013 8:49 PM (GMT -7)   
Interesting the issue is with Great West. They just participated in the CCFC education symposium (in Toronto) where they talked about how they cover biologics on most plans. The woman was mosthy there to tell us to shop around to different pharmacies because the price is different whether you go to a Shoppers, Wal-Mart, Rexall, Costco, etc. I never thought about shopping around for lower prices.

I am glad they finally 'got it' harbinson66, and I totally get the stress. mtooke keep trying with the insurance company. Tell your doctor too, as sometimes the orders of why they are suggesting one med over another isnt clear. Insurance thinks they know better, but remember they are all in it to make $ somehow. Trying to still figure out how a paper pusher with maybe a 3-4 year degree would know more than a doctor who goes to school for 8-12 years, but still the paper pusher rules....
13 daughter with Indeterminate IBD diagnosed at age 11-Sept 2012 Crohn's Nov. 2012
Now on Methotrexate, Prednisone, Entocort, Zofran, Prevacid, Immodium - Soon to try Humira
Built up antibodies against Remicade... Been on: Remicade, Flagyl, Cipro
Dairy free diet
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