After getting all the test results and talking with the doctor, it was recommended that my daughter go on either Humira or Entyvio pens. Because of my experience with it and its safety profile, we went with Entyvio. However, insurance denied Entyvio saying she needs to try Humira first. Okay. So doc’s office submitted the PA for Humira and that came back denied as well. Doc’s office is filing an appeal. I have not had to appeal for any of my meds thus far, does anyone have experience with this? What are the odds we still can’t get it after appealing? She has to go on something to treat this disease.
48 F
Diagnosed UC 2010
Entyvio every 8 weeks since 2018, Lialda, curcumin, vitamin D, probiotic
Is there anyone who can offer any insight? The letter of denial stated that she needs to try and fail Corticosteroids, 6mp, Azathioprine, or methotrexate. (Steroids make no sense to me since you can’t take them long-term anyway.) The doctor did not recommend any of these and I know Crohn’s is not like UC in the way it affects the body or is treated. Is it likely that this is what we’re going to have to do or could the doctor’s appeal be successful?
48 F
Diagnosed UC 2010
Entyvio every 8 weeks since 2018, Lialda, curcumin, vitamin D, probiotic
48 F
Diagnosed UC 2010
Entyvio every 8 weeks since 2018, Lialda, curcumin, vitamin D, probiotic
I can't offer any insight, but suggest you keep pushing your Dr./GI. They may be better adept at dealing with the insurance companies. If they tell you their hands are tied, you can do a course of Pred, with Imuran as maintenance and see how it goes. My Daughter took Imuran for 2 years, and ultimately failed it before going to Remicade. If you have to go this route, just be vigilant with the diagnostics. I would have scopes and MRE's every 6 months, plus regular blood work ups. Good luck, hopefully all is not lost if your Doctors can advocate for you.
Unfortunately this is a common problem when dealing with insurance companies. The law seems to vary from state to state. The CCFA has been trying to get legislation passed to prevent insurance companies from requiring patients to fail these older meds before they allow you to try the newer meds.
These meds can work and do sometimes, but their rates of success are lower than the new generation of treatments, and their risk of side effects are higher than the new treatments. So why do insurance companies require them to be tried first? Because they're much cheaper, of course.
You must be in a state that allows the insurance company to have these requirements. You and the doctor can try to appeal. I have no idea how well that works. It varies from state to state and insurance company to company.
These meds can work and do sometimes, but their rates of success are lower than the new generation of treatments, and their risk of side effects are higher than the new treatments. So why do insurance companies require them to be tried first? Because they're much cheaper, of course.
You must be in a state that allows the insurance company to have these requirements. You and the doctor can try to appeal. I have no idea how well that works. It varies from state to state and insurance company to company.
Thank you for the replies.
Yeah, I’m aware of why they do it, I’m just wondering how likely it is to get it approved on appeal without trying one of these other meds first. A few I will not let her try because I wouldn’t even try them myself. And I believe there is more risk with CD than UC in general. If it was UC I wouldn't hesitate for her to try the usual first line meds same as I did. They worked for me for awhile and are low-risk. I also wonder why this wasn’t mentioned to us by the doctor’s office because I even asked about “lower level” meds since I didn’t know a lot about Crohn’s and the answer was basically no, we need to go directly to biologics. I know my daughter isn’t the only patient with CD or the only one first diagnosed by their office, so they should know what to expect. I also didn’t know it was a thing for the insurance company to tell you that you have to try a certain med and then deny approval for the med THEY said you have to try. 🙄 Unless the doctor’s office knew they’d have to play this game and were confident they’d win. 🤷♀️ I guess we’ll see what happens and hope we don’t have to fool around with it too long. That’s the scary part. She’s doing well now and the only symptom she has is blood in her stool but that can change at any time which just puts her at higher risk for complications.
48 F
Diagnosed UC 2010
Entyvio every 8 weeks since 2018, Lialda, curcumin, vitamin D, probiotic
Yeah, I’m aware of why they do it, I’m just wondering how likely it is to get it approved on appeal without trying one of these other meds first. A few I will not let her try because I wouldn’t even try them myself. And I believe there is more risk with CD than UC in general. If it was UC I wouldn't hesitate for her to try the usual first line meds same as I did. They worked for me for awhile and are low-risk. I also wonder why this wasn’t mentioned to us by the doctor’s office because I even asked about “lower level” meds since I didn’t know a lot about Crohn’s and the answer was basically no, we need to go directly to biologics. I know my daughter isn’t the only patient with CD or the only one first diagnosed by their office, so they should know what to expect. I also didn’t know it was a thing for the insurance company to tell you that you have to try a certain med and then deny approval for the med THEY said you have to try. 🙄 Unless the doctor’s office knew they’d have to play this game and were confident they’d win. 🤷♀️ I guess we’ll see what happens and hope we don’t have to fool around with it too long. That’s the scary part. She’s doing well now and the only symptom she has is blood in her stool but that can change at any time which just puts her at higher risk for complications.
48 F
Diagnosed UC 2010
Entyvio every 8 weeks since 2018, Lialda, curcumin, vitamin D, probiotic