Insurance will not approve Enbrel. Need advice for the next step! [Archive] - National Psoriasis Foundation message board

Caki

08-21-2006, 08:00 AM

I have pppp and pa. I want to try Enbrel. I do not want to take MTX. I know it works for many folks, but I'm deathly afraid of the liver issues and side effects. I also do not want to give up my cocktails when I want them.

Blue Cross just turned down the doc's recommendation for Enbrel and I know I have to go through some sort of appellate process, but I need to know any other things which might help me in getting approval. Any other avenues? Anything any other docs did to help another poster here bypass MTX for Enbrel?

I need help! The doc has had me on prednisone temporarily and I know I need to get off of it soon. I'm blowing up like a big balloon and the sweating is really awful in the heat of this summer.

Thanks so much for any advice anyone can give. I really need some guidance.

MikeK

08-21-2006, 08:23 AM

Hi Caki,

I'm so sorry! File an appeal. Also, please give the NPF a call. They have an insurance advocacy service that goes to bat for people who are having insurance issues. (Here's a link to their description of their service: http://www.psoriasis.org/advocacy/assistance/insurance/appeal.php and here's a link to their contact information: http://www.psoriasis.org/contact/.) You also might want to send a letter to your state insurance commissioner. You can find his or her contact information in the phone book or on your state's "official" website. (Just so you know what to look for, I'm from New Jersey and here's what our "official" website looks like: http://www.state.nj.us/.)

I hope this helps!

Good luck. Keep us posted.

Mike

SumScalyGuy

08-21-2006, 08:23 AM

File an appeal yourself directly with the insurance company. Also, have the dr's office file an appeal as well. Contact Enliven Services and give them your insurance info.....they helped me the most. I have Blue Choice (an HMO division of BCBS). It took almost a month, but they finally approved it.

PS....It doesn't hurt anythihng to mention the psychological impact it is having on you in your appeal letter to the insurance company.

SumScalyGuy

08-21-2006, 08:26 AM

Also, my insurance didn't require that I first try MTX (which I did)......Their guideline was that you have to "be a candidate for systemic drugs", not actually use them all. Hope that helped a little. Let me know if I can provide any additional info.

Good Luck

SuzanneT

08-21-2006, 09:07 AM

Caki, Blue Cross approved Enbrel for me, and I only (!) have PPPP, not PA. However, when I went to get the Rx filled, I found that there was a copay of approx $800 per month. Check your policy, I know that my Blue Cross plan recently changed the policy so that they only cover injectibles at something like 20%. I have since switched to Kaiser, knowing that I will most likely end up with Enbrel.
Sue

jperng

08-21-2006, 09:22 AM

Hi Caki,
Sorry to hear your insurance problem.
Just wondering which doc prescribed enbrel for u? was it your Derm or your Rhemy?
I had issue getting my enbrel when I swithced insurance company about 2 years ago. My Derm prescribed enbrel for me since my old Rhemy was not in my new insurance's network anymore and I got denied. I found a new Rhemy in my network and he prescribed and certified it for me.. and there was no issues at all. I think Enbrel was already approved for PA and P at that time.
Hope that helps

Stillworking

08-21-2006, 05:21 PM

Having a rheumy write the script will surely help and contacting Enliven is also a great suggestion. Enbrel was recommended for me at first, but the co-pay was over 700 per month. I'm now on Remicade which is covered at 100% because it is an IV infusion. Each insurance is different, you need to find out how much will be your co-pay and then file an appeal if that is right for you. Good luck

Caki

08-21-2006, 07:10 PM

Thanks to everyone for the tips and keep them coming. If there's anything anyone's doc included in the appeal, it would be helpful. My rheumy is the doc who prescribed enbrel. I was hoping that would help. I'm not sure how strong my doc worded the request for authorization. I'm going to hope that he will word the appeal very strong. If not, I may have to switch docs and I'll leave the state if I have to, to do it.

I know my co-pay will probably be pretty high. I'm not sure what it will be, but I will figure out a way to make it work, somehow.

Thanks so much!!!

PJ Leary

08-21-2006, 09:09 PM

Hi Caki,

I am a long time p & pa patient and have fought and won many appeals with multiple insurance companies over the years. My last big fight was just this year with BCBS ( IL ) over coverage for Remicade. But that was just the last. The very best thing I can tell you is to stay on top of it, use every available resource, and do not give up.

I am living proof that it is possible to wear down any insurance company when there is a clear indication that the medication is warranted. The Foundation will write letters of support, contact them. Appeal the process yourself, and ask your doctor to do the same. Request a second opinion. Above everything, do not give up.

I firmly believe from personal experience and also from the number of people that I have advocated for over the years that insurance companies count on the fact that most people will simply go away after one or two denials. It really is a case of the squeaky wheel and all.

The last time I appealed, there was an advocate available through work for health insurance issues that would assist with negociations with BCBS. The most important thing that person did for me was to witness the calls to BCBS and document as a third party the conversations. Use Enliven, contact the Insurance Commissioner in your state ( they are very lonely people and don't talk to many patients ), use the Foundation, and any other available course of attack, and use them all at once!

Please keep us informed of your progress.

Regards,

Caki

08-22-2006, 08:39 AM

Thanks, PJ. Blue Cross wants me on MTX, first. Any pointers on how to get around that? Any specifics that I and/or the doc can put in the appeal which would be persuasive? I was hoping my doc's initial request would be very persuasive.

Caki

08-22-2006, 09:35 AM

I should probably also mention that I'm in Louisiana and the Insurance Commisioner's office has had his hands full since Katrina and still does. Actually the Ins. Comm. resigned and a temp is in his place, who is currently running for office. I'm not sure if that will help or hurt! Thanks so much for the advice.

PJ Leary

08-22-2006, 08:36 PM

Hi,

I recall reading that the American Academy of Dermatology announced their support of biologic therapy , including enbrel, as a first line treatment for moderate to severe skin disease. However, when I looked for an article I could not find the reference.

I did find this reference stating that a recent study indicates that 48% of all patients using mtx are unable to continue treatment after a year.

http://www.medicalnewstoday.com/medicalnews.php?newsid=16703

A friend of mine had that happen to him at the VA ;ast yar, and I suggested that he ask the doctor saying that to put it in writing. Of course, that was the VA trying to save $$, not the insurance company. In his case, the doc was not willing to put it in writing and he got the enbrel script.

In your case, you need to read your policy very carefully, and go through the appeal.

Regards,

Caki

08-23-2006, 11:53 AM

Thanks, PJ. The insurance claims it's not medically necessary and that I have to have the MTX or something similar fail before I can get Enbrel. I absolutely do not want that MTX. I know some have had success with it, but I don't want to take it. I can't afford the side effects either. I'm willing to do whatever it takes to get this accomplished.

Momelie

08-23-2006, 05:25 PM

Is sulfasalazine an option for you? I tried that before I went on Enbrel, as I'm not a candidate for MTX due to liver issues. Caveat - I mainly have PA with minimal P, so my rheumy focuses on PA.

Caki

08-23-2006, 08:45 PM

I've considered sulfasalazine as an option. I have pretty active P, though, which worries me. If the sulfasalazine doesn't work, I don't think I can then got to Enbrel. I think the ins. co. would still want me to try and fail at MTX first.

I'm scared of the stomach issues with sulfasalazine, though potential weight loss is very appealing. Did you have any problems with it?

PJ Leary

08-23-2006, 09:52 PM

hi Caki,

Why not consider a short course of cyclosporine? It has it's downside to be sure, but it is considered in the same class of medication by most insurers, including BCBS. I went through this whole part of my policy with BCBS earlier this year myself.

In my case, the policy clearly stated that failure of either mtx or cyc would indicate a possible move to biologics. However, I can tell you for sure that when we all read the fine print together, the policy clearly stated that the patient did not have to try and fail either of those systemics to be apporved for biologic treatment.

Get a copy of your policy. Or, call your insurance company, have a witness on the line ( make that known ), and ask to have that specific part of your policy read to you and explained clearly. BCBS has been outright denying biologic claims for some time, and it can be a big fight to get them covered. Due to the high cost, their first, second & third line of esponse is no, no, and NO.

Good luck, dear!!

Caki

08-24-2006, 07:58 AM

PJ, Thanks for that suggestion and I'll look into that. I'm not familiar with that medication and will look it up. I've got my policy at the office filed and have had it pulled to get it to me so I can read it VERY CLOSELY. I surely hope my policy has that "fine print" in it. If it does, I know just how to handle that. If it doesn't, I'll have to really look hard for some other guns to go in with. Some time back, a poster said in another thread, that he/she skipped MTX and went on to Enbrel. My understanding was that the doc wrote something that got the poster past the policy language. I believe I posted there asking what the doc argued, but never saw a response. I was hoping to come up with some "magic" language the doc could use to get past the problem, in the event that I cannot argue the policy language.

I so appreciate all the help! It's just so valuable.

Caki

08-24-2006, 08:42 AM

I looked up information on cyclosporine. It appears to be contraindicated for persons with high blood pressure as that is a side effect. I take meds for HBP. I haven't had HBP in I don't know how many years. It always runs perfectly normal on the meds, so apparently they work fine. Thanks for the suggestion, though. I want to look at as many options as are out there.

bigpede

08-24-2006, 01:57 PM

seedoubleyou

08-24-2006, 02:10 PM

Hi Caki: Sorry to hear about the difficulties you're having. I suspect I'll be facing a similar situation soon so I'll admit I read threads such as this one with great interest. I've resisted the bios thus far but it's looking more & more like that's my future, like it or not. I have BCBS, also (PPO/Arizona). (Another thing we have in common -- I DO NOT want to go the MTX route!!)

Wanted to add my $.02 on SSZ, though. I've been taking it since February '05, and have been on the higher dosage (3,000mg/day) for over a year now. It worked great for me -- for a time. However, since I injured my knee in January (injury required extensive surgery and I subsequently developed a neuro disorder called "RSD"), PsA has been flaring. Rheumy has followed my case closely and had high hopes that once the RSD was under control, the PsA flare would subside. That has not proven to be the case.

I've also been on Celebrex for several years, and etodolac (400mg, 3xday) since knee surgery.

Though my stomach has pretty much always been "cast iron," in the past few months I've developed gastric bleeding. Will 'fess up that I was drinking with the aforementioned meds (plus, the boatload of others that I take). Knew that was a no-no, especially at the high dosages that I'm on, but ... well ... I did manage to get the tummy under control and am back on the meds as scheduled at this point, still hoping (naively??) things will improve before next rheumy appt.

SSZ is not the greatest drug for Ps so if your skin involvement is substantial, I'm not sure I'd waste my time. The drug is primarily used for the treatment of inflammatory disorders such as RA & Crohn's. In cases such as yours (ie, Ps + PsA), SSZ is generally used along w/MTX or another systemic beneficial to the skin.

As for the weight loss, I DID lose quite a bit after my SSZ dosage was increased from 2,000mg/day to 3,000mg/day ... unfortunately, thanks to a couple of months in a wheelchair/on crutches, I gained it all back -- & then some!!

On the plus side, the drug is cheap &, unlike so many of the newer treatments available, long-term studies abound.

Hope this helps a bit. Again, I appreciate so much you sharing -- suspect it'll prove to be of "tutorial" value to me soon!!

Caki

08-24-2006, 08:27 PM

Cat,

Thanks so much for that information. I assume SSZ is sulfasalazine. I'm not up on all the lingo! I'm worried about the fact that it's not as effective and doesn't help the P. I was thinking if I took it, maybe I'd ask about trying the Keflex another poster recently reported as helping her with the P. This is all so confusing. I went 6 months after my first flare of PA and P perfectly clear, no pain and no drugs. When it suddenly reappeared, it did so with a vengeance. I'm coasting temporarily on prednisone right now, which I despise and which is not making my rheumy terribly happy. He reduced the dosage recently and I'm breaking out again on my hands and feet. It's not horrible, but it's there. I'm a little sore in my knee joint too and I know that isn't good. It hasn't filled with fluid yet and I'm not running fever as I usually do when it gets good and filled. I know I have to do something fast to avoid damage. I'm getting worried, without a doubt.

Thanks so much for your 2 cents! It's worth a lot more than that and I hope you find the solution of your choice!

PJ Leary

08-24-2006, 08:41 PM

Hi Caki,

While hbp is contraindicated with cyc, I used it on and off in my 30's while taking a calcium channel blocker for hbp as well. My bp was fine. It is on remicade too.

The thing is that it is in the same classification as mtx, and far less of a worry. It could be that the doc made a notation in the chart that one glass of red wine had been suggested daily as a preventative measure for heart and cholesterol health in lieu of medication with positive results. That would nix the mtx then and there. Just a thought.

Read the fine print, and let us know what it says. When you do get your hands on the policy, make a copy and send it to the Foundation. They will do good things with it for many people. The only way they can see any policies is when members voluntarily send them in.

Regards,

PJ Leary

08-24-2006, 08:51 PM

Hi Caki,

Link:

http://www.psoriasis.org/forum/showthread.php?t=19225

Regards,

Caki

08-24-2006, 11:35 PM

PJ, you are a gem and I can't thank you enough for all of the valuable information.

I just got my policy. You mentioned you found some "fine print". I can't find that in mine, but perhaps I'm not looking in the right section. I read policies all the time, but not usually health policies. Seems harder when you are doing it for yourself, for some reason.

I was hoping that since I take meds for cholesterol, I might bypass the MTX, but apparently, that's not enough.

The red wine suggestion is good. I'll look into that as well.

Thanks again so much!

It would be nice to make that other link at "sticky" thread!

PJ Leary

08-25-2006, 06:43 AM

Caki,

Call your insurance company and ask them to read it to/with you. It is hard, you are right. But, you need to do it. Today. Don't forget to send a copy of it to the Foundation. You can fax it to: 503-245-0626

Regards,

SuzanneT

08-25-2006, 10:22 AM

Hi Caki,

Just to throw in my 2 cents.... Back in May I spoke with the Encourage Foundation, trying to get help with the Enbrel copay. I had already been approved for Enbrel, but found out that my BC Ca copay would be very expensive, since my policy changed the copay on injectibles. Here's a link to that post http://www.psoriasis.org/forum/showthread.php?t=19941 and my reply...

"I spoke with them yesterday. They were quite helpful - however the woman told me that they had been inundated with requests and that they were running out of funds. It used to be unlimited, but now there is a max of $1400 per patient. With my Blue Cross deductibe ($791 per month), that would only cover two months for me. Even if I did qualify financially, which I doubt that I would."

Caki, I hope that you are successful with this. As another PPPP sufferer, I know what you're going through. There is nothing that would make me happier than to hear success stories of biologics for PPPP.
Sue

Caki

08-25-2006, 10:02 PM

Suzanne, thanks for your post and I'm so sorry you are not having a favorable time. I'm hoping that if more folks find success with the biologics, the price will eventually tumble, so that those who wish to try them can without all the hassle (IN OUR LIFETIME!).

I hope you get relief in every way!

SuzanneT

08-25-2006, 10:37 PM

Caki,
Blue Cross approved me for Enbrel for PPPP with no questions asked!! My doctor submitted and it was approved within a few days! I was surprised, as I had heard horror stories of people having to fight for it.

The point is, that there is definitely a precedent for BC to approve Enbrel for this particular form of P, and you also have PA to boot! I'm sure there are many others here who have gotten approval from BC for PPPP. Maybe that would help your cause?

One other thing that I did was to give my derm photos of my feet - and if you've seen any of the photos I've posted in other threads you know that it ain't a pretty sight! :eek: Maybe you can take some pics and give them to your doctor for your appeal?

I have since switched to Kaiser. The main reason that I switched is because Kaiser only requires a minimum copay for biologics, and I am anticipating that I will need to go that route shortly. And the nice thing about Kaiser is that if your doc prescribes a med - you GET that med. No fighting any insurance company.

I wish you luck. Keep fighting! :)

Caki

08-25-2006, 10:51 PM

Suzanne, what great advice. I wonder if your BCBS policy required the "DMARDS" first as mine claims to. If so, I wonder what your doctor put into your request to get you approved.

I have insurance through my employer, so I probably can't switch, but I will keep Kaiser in mind and look into it.

I wish I had thought to take photos of my hands and feet when they were really bad. I'm only having a mild breakout right now, since I'm on the prednisone. I might have to talk with my doctor about going off so I can take those photos. I know I will have a PA flare if I do, though, and they've been pretty awful lately. I'm willing to withstand the pain, though, if my doctor will approve. The last two times I had to be drained and I was pretty sick from all the infection. Got an injection and back on the prednisone which helped a lot.

Thanks again!

SuzanneT

08-25-2006, 11:10 PM

I don't think so. I've never been on oral MTX, only topical MTX. I do NOT want to try MTX, since I have colitis (can't even take NSAIDS) and had an ulcer in the past. Also, I've lost 1/3 of my hair from Soriatane and refuse to take anything else that will cause me to lose more hair. When I saw my derm last month, we discussed biologics and I told him I wasn't quite ready yet. I'm on treatment #40 Narrowband, and just today added coal tar and sal acid. I'm going to give this treatment a few more weeks before I make a decision. However, I AM researching, and think that Remicade might be my best option now if needed. I don't have PA (at least rheumy says I don't, I'm not too sure!), so my PPP is my major concern.

I also have my insurance through my employer. I went in to HR a few months ago and asked if Kaiser was an option. They said yes, but there was only a window of one month during open enrollment when I could make the switch. It just happened to be that month, so I switched within a week. It doesn't hurt to ask! I have been VERY happy with Kaiser, and I investigated it pretty thoroughly before I switched (there are some old posts here about that and responses from several who have Kaiser and are on Enbrel). Yes, it's a good idea to take pics, if only for your own reference. I gave the derm pics of hands and feet going back to 1996. My PCP even scanned them into the system, so that any Kaiser doc I see now brings up pics of my feet (larger than life) as soon as they walk in the door to see me and brings up my file on his/her computer. :D

Caki

08-26-2006, 12:08 AM

Suzanne, I'm so sorry you've had such difficulties and I really hope you don't have PA. It's enough to deal with PPP. Plenty enough. A good while back, I posted about a cream my dermy prescribed. It's really helped me in that it takes care of those pustules very quickly and the itch. This cream or mixture is an RX and it reads "ICTHAMOL 3%/ZNOX PST. I've forgotten what the dermy said was in it. Looks like it could have a little tar, but I don't know. He told me the only place he found it was at a pharmacy in Memphis. It's mixed at the pharmacy. The name is Super D Drug Store. The number is 901 726 4444. I think it's about 10 dollars with my insurance and the container looks to be about a pint. You use it "sparingly" about 2-3 times a day. It disappears into the skin fairly quickly. The consistency is that of the zinc like you put on our nose to keep from getting sunburned. One container lasts a very long time for me.

If you're interested, you could call the pharmacy to find out the mixture and discuss it with your dermy. I just call and order it with my credit card and it comes right away. I can't recall what shipping is. Not much I don't believe.

You have given me a world of information and the tip on Kaiser is a good one. My insurance doesn't renew until next February, but I will keep that in mind and start looking into it now. Thanks soooo much!

bbffrrpp

08-26-2006, 01:14 PM

Hello. Just wanted to say that sometimes I result to being sneaky - as a "survival technique."

I know very little about what is being discussed, and need to find out what ENBREL is. But, if an insurance company is saying that you need to try MTX, first. Why not get the prescription, and not use it ? "Pretend" you used it - and let it go at that!

Having said that, I don't know what it will cost you to do this !

Betty

(near Lowell, MA)

SuzanneT

08-26-2006, 02:10 PM

MikeK

08-26-2006, 02:43 PM

I know very little about what is being discussed, and need to find out what ENBREL is.Hi Betty,

Enbrel is one of several medications that are part of a exciting new class of drugs called biologics. A biologic may be prescribed for someone who has severe psoriasis or psoriatic arthritis or PA. In the case of PA, a biologic can actually prevent joint damage, which is pretty exciting. All of the biologics are very expensive, which is why some insurance companies make people jump through hoops before they'll approve them.

Here's a link to the NPF's discussion of biologics: http://www.psoriasis.org/treatment/psoriasis/biologics/ and here's some links to some additional information about Enbrel: www.enbrel.com and http://www.pdrhealth.com/drug_info/rxdrugprofiles/drugs/enb1159.shtml.

I hope this helps.

Mike

MikeK

08-26-2006, 02:57 PM

Caki, I thought that Icthamol sounded familiar! Isn't it black, gooey stuff? I remember from when I was a kid, if this is the same thing. It's available over the counter, see pic below.

Maybe Mike will know? I thought I remembered a post about this before?I have to confess that I'm not familiar with Icthamol.

It sounds like Caki's doctor gave her a prescription for something tha had to be compounded by a compound pharmacy: http://www.iacprx.org/site/PageServer?pagename=What_is_Compounding. We just had a discussion about compounding coal tar and Aquaphor http://www.psoriasis.org/forum/showthread.php?p=252333&highlight=compound#post252333. I'm no familiar with the ingredients that Caki mentioned -- it sounds like there's at least two of them in the script -- Itchamol at a certain strength and ZNOX PST, which are probaby abbreviations for one or more medications. It's possible that that particular strength of Itchamol is available by prescription only; it's possible that ZNOX PST (separately or together) may be available by prescription only. I didn't see ZNOX PST in the list of medical abbreviatons that I gave as a link in my post in the other thread.

I hope this helps.

Mike

Caki

08-26-2006, 03:13 PM

Suzanne, this stuff I use is not black and gooey. It's sort of light gray and it creamy, but also sort of like desetin (sp)), though not quite. The doc gave me unlimited refills for about a year. I've only filled it 3 times. I had a six month period of being clear after he gave me the RX. That ended in March. I wish I could be more helpful with the information. I know that it is mixed at the pharmacy, it's cheap and it helped. The pharmacy is probably the best source for exactly what's in it.

seedoubleyou

08-26-2006, 03:46 PM

My guess -- and that's all it is -- is that the abbreviation, "ICTHAMOL 3%/ZNOX PST," may stand for:

Icthamol 3% zinc oxide paste

And yep, icthamol is that ooey, gooey black stuff many of us probably had slathered all over us in our youth.

(Myself, I remember that green "horse linament" my mom used to rub on my aching legs, the alum she'd dab on ulcers in my mouth :eek: , and what we called "monkey blood" on scrapes!!)

SuzanneT

09-09-2006, 09:02 PM

I found a tin of ichthmyol in the drug store. I tried it for a while, and used zinc 40% at the same time. My foot is a lot worse now, and it's also started back on my hand. :eek: My light treatments are NOT doing any good. Saw my derm again yesterday and he suggested I start Enbrel. He said he would Rx Remicade if I wanted, but would like to see me try Enbrel first. As soon as my chest xray results come back, I have an appt for first time injection instruction on Wed. My copay will be $25 (as opposed to the $800) per month with Blue Cross. No questions asked, no paperwork, no insurance denials. How are you doing, Caki? Any luck with Enbrel?

sherryflowe

09-11-2006, 06:57 AM

Caki,
I JUST went thru this with Blue Cross. I was crushed!!!!!! Although my Doctor was going to start the "paper" appeal, I begged him to pick up the phone and CALL them. He did, and they reversed their denial for my Humira!!!! If the doctor deems a drug such as Enbrel or Humira necessary (and other avenues have been explored) it seems to me that the Doctor should know best....NOT the insurance company. I sure feel your pain, girl. This is just a suggestion, BUT it worked in my case. I will be praying that you are able to get a go ahead for the meds!!!!!

Good luck!

Caki

09-29-2006, 07:23 PM

No luck yet. Still getting some things together. I ordered some materials and have been reading some additional materials to strengthen my case. I found a friend who got it approved a while back and she just sent me a copy of a letter she wrote to help me out. Thanks for asking. I will definitely report on the results.

SuzanneT

09-29-2006, 08:12 PM

Caki,

Don't give up!!! I've been on Enbrel for 2 weeks now, and I am almost afraid to say it, but I am almost clear! The pustules were gone in a few days, and every day it's getting better and better. I can't believe it - this is the best my foot has been in years. And my hand is 100% clear!! I've been taking pictures since I started, and I'll post them this weekend. Keep fighting!

Sue

Caki

09-29-2006, 11:06 PM

Suzanne,

I can't tell you how happy I am for you! I can only imagine how you must feel. Bask in it! It just makes me smile to know someone is getting relief. We all deserve it so!

Do you have PA as well?

SuzanneT

09-29-2006, 11:22 PM

Hi Caki,

PPPP has to be one of the most stubborn things on the face of the earth! I've been fighting it for 12 years, and NOTHING has ever worked like this before. I can't tell you the hope that it's given me in the past week, and the fact that this might also help others with this. I'll post more this weekend, when I can sort out the pics.

Hmmmm.... I suspect that I have PA, although rheumy thinks it's just arthritis or stress. Here are a couple of threads where I have asked a lot of questions about it.

http://www.psoriasis.org/forum/showthread.php?t=19857

http://www.psoriasis.org/forum/showthread.php?t=20373

Interesting, while I have seen some pretty dramatic improvement in my P, I haven't seen any change at all in my back / hips. Maybe it's too soon to tell for that? Or maybe it's not PA? I don't know.

sherryflowe

09-30-2006, 07:42 AM

Caki,

Girl.....I know exactly what you are going thru!!!!! It is exactly what BC "suggested" I try before they would approve Humira. My Doc was going to start the appeal process butI callled him (I was VERY upset!) and asked him to call Blue Cross directly and tell them that in his opinion I really needed Humira or Enbrel. Guess what.........within 2 days they approved the Humira. Just a suggestion, but it worked for me. The best of luck to you. Insurance companies make me sooooo mad!

niadancer

10-01-2006, 04:48 AM

Caki,
My friend has Blue Cross of Central NY and the doctor simply wrote them a letter of medical necessity and he got his Embrel. Keep at them! Good Luck

Caki

01-22-2007, 01:16 PM

I posted this in another thread, but this thread might be more helpful to others. I got approval for Enbrel at the end of last week, finally, after appealing. My doc was not at all optimistic about me getting approval. I think he wrote a pretty light letter the first time. I sort of raised a little cane when I insisted we appeal. I told him he was my advocate and he should be strong in his letter this time. I gave him a list of things to include and some copies of some info from this site and board. Again, he was slow about writing the letter. I called to find out if they'd heard anything and found that the letter hadn't even gone out, 6 weeks later. I think there's a staffing problem, but anyway, I took myself right over to his office, saw him, got pretty darn firm and embarrassed him, basically, over his delinquency. He seriously didn't realize the letter hadn't gone out. It went out darn quickly after that and we got approval. I don't mean to speak poorly of my doc as I really like him. He's written on PA and I do trust him, but he needs to get his staff together. In any event, I fought and won.