Blue Cross sucks!!!!!!!!!!!!!

[sherryflowe]

Well, just when we thought I'd be able to start on Humira, Blue Cross denied it! I guess they would rather wait until my SI joints are damaged (which they aren't yet). My Rheumy's nurse just called and said they are starting the appeal today. Blue Cross says I haven't tried enough drugs yet so my doc wants me to take Methotrexate while he appeals. I already have an ulcer and bleeding leasions on my upper intestinal track due to to taking anti inflammatory drugs. I read it can cause liver damage but I'm wondering about my poor stomach. I guess I'll have to try it and pray the isurance company will do the right thing for a CHANGE. My ins. payments are $474/month and go up every Oct. Unfortunately health and insurance issues aren't a priority to this administration. Can't seem to stop crying today! Boy if stress is bad for PA, wonder what it's doing to my blood pressure. Didn't have high blood pressure until recently. Any thoughts?

[dlruss]

Sherry, that sucks. I mean really sucks...

Not sure if it would make a difference, but maybe the injectable MTX would be easier on your stomach than the pills? I've heard it takes away some of the side-effects...

[Caki]

Sherry, I am with ya sista! See my recent thread on this.

http://www.psoriasis.org/forum/showthread.php?t=21144

I hope some of this information helps you.

I am very upset and I can understand your disappointment, especially with the stomach issues. Don't give up, though. Just keep fighting!!! GET MAD!!! I know I am. I do better mad than sad.

I wish you the very best in your appeal.

[MikeK]

Hi Sherry,

I don't think that we've met so let me take this opportunity to welcome you to the Board. Nice to meet you. :cool:

I'm sorry to hear that you're having issues with Blue Cross. Please give the NPF a call. They have an insurance advocacy service that goes to bat for people who are having insurance issues. Your state insurance commissioner or department may also be able to help.

Here's a link to a very informative discussion about Caki's insurance issues:

http://www.psoriasis.org/forum/showthread.php?t=21144.

And, here's a link to a very old thread that describes how the NPF helped one family get coverage for a home light unit: http://www.psoriasis.org/forum/showthread.php?t=5155.

I hope this helps.

Hang in there!

Feel better.

Good luck and please keep us posted.

Mike

[RichJ]

hi sherry,
im so sorry to hear that. i hope that straghten out for you. polly has the same problem on getting on enbrel. i to have stomach problems and like a shoe in stead of a pill. my new med i think is startting to get to me. i wish you the best

try and have a good night all

richard

[ppt]

All BlueCross plans are not the same...they are independent licensees from the BlueCross BlueShield Association. I have BCBS and my Humira RX was covered (other than my drug-copay) with no questions asked. Sometimes the coverage factor is also due to what the employer chooses to buy from BCBS and offer to their employees

[Resist]

BlueShield of California is even worse!

[Caki]

All BlueCross plans are not the same...they are independent licensees from the BlueCross BlueShield Association. I have BCBS and my Humira RX was covered (other than my drug-copay) with no questions asked. Sometimes the coverage factor is also due to what the employer chooses to buy from BCBS and offer to their employees


That's certainly true. I am under the impression that mine is a coverage factor due to the plan and not due to what my employer purchased. However, I will look into that and thank you for pointing that out.

[PJ Leary]

Hi,

I join Mike in welcomeing you to the forums. You came to the right place. I've posted in Caki's thread, and I'll post to you here too. Follow Mike's advice, and send them a copy of your policy. Read it carefully.

Today I do not believe that any insurer can require mtx before biologic, it is morally reprehensible to do so. If they do end up sayinfg that, it is worth a big fight and the Foundation will help to take that on. They made great progress with gaining access to biologic treatments for patients in CA with BCBS.

Do not give up. Learn the appeal process, call and ask them, they will tell you.

Here is a link that may be helpful:

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

Good luck, and be the squeaky wheel!

Regards,

[wildflowerAnn]

Yes Blue Cross makes you try the least costly medications first before paying for biologics which cause everyone's premiums to rise. Blue Cross tracks the prescriptions, the failures of the biologics to be effective, the changes to new biologics, and the total costs. Just because a person wants to keep drinking is no reason that Blue Cross should foot the bill for an Rx that costs so much, when a drug that costs $30 per month will suffice. We all pay for this. There are many posters on these message boards who use Mtx successfully for years and have no problems, and are able to quit drinking to use the medication. I'm glad Blue Cross keeps the costs down. The premium increases and co-pays keep rising every year, and if consumers don't help keep the costs down, then employee health plans will just be cancelled; e.g. General Motors.

Resist saved Blue Cross money by getting his own unit. That saves me money.
That should be the approach, rather than trying to ask the physician to misstate the facts or work around the rules so that a person can keep drinking.
Ann

[Caki]

grannyfranny's post in your thread about a PCP is a big reason I don't want to take MTX. I have missed enough work from this disease and cannot afford to have that side effect or some of the others, not to mention the possible effect on my liver which is already at risk on cholesterol meds I take.

[sherryflowe]

Hi, its me again. Wanted to clarify something....I pay for my OWN insurance :( out of pocket as I am a REALTOR (only doing referrals now though). My main complaint it this......given the fact the BC SHOULD know that TNF blockers will treat the disease and not just the symptoms, seems like they would want me on either Enbrol or Humira since I don't yet have bone damage!!!!! I've been so upset about the denial, we have decided to put everything on hold for the week end and start writing the letters on Monday. THANKS so much for the info guys! I read the "mock up" letters we can use to write to the insurance companies that the foundation has provided. Monday I'm gonna get right on it. Oh, another question! I'm not a big drinker, but we always go to the Mexican caribbean in Oct to celebrate our anniversary and I do intend to enjoy my pina coladas. Will a few days of drinking damage my liver if I'm taking the Meth? :eek:

[ouchyk]

Just because a person wants to keep drinking is no reason that Blue Cross should foot the bill for an Rx that costs so much, when a drug that costs $30 per month will suffice

That should be the approach, rather than trying to ask the physician to misstate the facts or work around the rules so that a person can keep drinking.
Ann


Where in this thread is drinking mentioned?? :confused:

I see gastro problems with nsaids in the orig post!, who should be DICTATING what a patient can and cannot take?? The patient and doctor OR the insurance company??!!

Did you ever stop to think that people MIGHT have health circumstances where they cannot take a dmard?

Sherry and Caki keep fighting! Enlist the NPF advocacy dept to help you!

Wishing you all the luck in getting what YOU want to try!
Karen

[grannyfranny]

Did you read the link posted in this message?


Where in this thread is drinking mentioned?? :confused:


Karen

Sherry, I am with ya sista! See my recent thread on this.

http://www.psoriasis.org/forum/showthread.php?t=21144

I hope some of this information helps you.

I am very upset and I can understand your disappointment, especially with the stomach issues. Don't give up, though. Just keep fighting!!! GET MAD!!! I know I am. I do better mad than sad.

I wish you the very best in your appeal.
__________________
I wish you no P breakouts and no pain!

[ouchyk]

No. actually I didn't read that link.

but I did read this comment;

grannyfranny's post in your thread about a PCP is a big reason I don't want to take MTX. I have missed enough work from this disease and cannot afford to have that side effect or some of the others, not to mention the possible effect on my liver which is already at risk on cholesterol meds I take.

http://www.psoriasis.org/forum/showpost.php?p=252572&postcount=11

It should be up to each individual as to what they wish ( or don't wish ) to use as medication for thier P/PA not the insurance company.

I hope they both win thier appeals and fight this tooth and nail!

Karen

[grannyfranny]

MTX is different with everyone. Some people take it for years without problems.

[Caki]

Mea Culpa! Mea Culpa! Guilty as charged! I said in my thread that, in addition to my other fears of MTX, I would like to enjoy my cocktails when I want them.

Regardless of my fears, I believe I that when there are acceptable medications out there that I can try, I should have the option. I should have a say so on what I take. Others may disagree and I respect that.

I researched and diagnosed my own P and PA last summer. My docs couldn't figure it out. They diagnosed me with all manner of other things. For a year, I've researched and read about medications. I believe you should participate in your plan or, at least, try. I may not have a choice, but I can fight for one and I intend to. I know my body better than anyone else. I also know my emotions and my state of mind better than anyone else. I'm glad many people have had success with MTX and I applaud that. I would prefer another option. I don't believe anyone should be called down for having a preference. These diseases are very personal, I've found. I own it and when you own something, you should have some say so.

Those are MY feelings and I hope they will be respected as I respect the feelings of others. I wouldn't begin to chastise someone for their choice. I will be happy to offer suggestions or advice or experiences or support.

Isn't that the way it should be?

I've found that these diseases take a lot away from the quality of life or can, anyway. Everyone has different interests and different things that mean a lot to them. P and PA can whittle down the list of what you can and can't do. If people get enjoyment out of having wine with dinner, then they should be able to have that option, if they want it and can have it. Sometimes little things in life become big things when you are struck with a disease. Hanging on to those things can make a difference in your emotional well being, which is a big part of dealing with whatever it is you have, in MY opinion.

Hope I haven't offended anyone.

[Flannel]

You can't get the rx you need and I can't get them to insure me. They listed P as the #1 reason and my being 20 lbs overweight. My agent is going to fight it but I don't see them winning. BC suggested I get HIPAA High Risk insurance or something which I don't qualify for because I haven't satisfied the COBRA requirement (which I can't afford). There I feel better somebody else thinks BC stinks!!

[MikeK]

You can't get the rx you need and I can't get them to insure me. They listed P as the #1 reason and my being 20 lbs overweight. My agent is going to fight it but I don't see them winning. BC suggested I get HIPAA High Risk insurance or something which I don't qualify for because I haven't satisfied the COBRA requirement (which I can't afford). There I feel better somebody else thinks BC stinks!!Yikes, Ginger! I'm so sorry. Please give the NPF a call. They might have some suggestions for you.

Mike

[SuzanneT]

Good grief! 20 lbs overweight? I wonder how many people in the US are 20# (or more) overweight??? :eek: Good Luck!

[seedoubleyou]

Mea Culpa! Mea Culpa! Guilty as charged! I said in my thread that, in addition to my other fears of MTX, I would like to enjoy my cocktails when I want them.
Myself. Having said that, the freedom to be able to have a drink when or if I choose is not MY primary reason for resisting MTX, either. Read on.

Regardless of my fears, I believe I that when there are acceptable medications out there that I can try, I should have the option. I should have a say so on what I take. Others may disagree and I respect that.

I researched and diagnosed my own P and PA last summer. My docs couldn't figure it out. They diagnosed me with all manner of other things. For a year, I've researched and read about medications. I believe you should participate in your plan or, at least, try. I may not have a choice, but I can fight for one and I intend to. I know my body better than anyone else. I also know my emotions and my state of mind better than anyone else. I'm glad many people have had success with MTX and I applaud that. I would prefer another option. I don't believe anyone should be called down for having a preference. These diseases are very personal, I've found. I own it and when you own something, you should have some say so.

Those are MY feelings and I hope they will be respected as I respect the feelings of others. I wouldn't begin to chastise someone for their choice. I will be happy to offer suggestions or advice or experiences or support.

Isn't that the way it should be?
Yes!! Well said!!

I've found that these diseases take a lot away from the quality of life or can, anyway. Everyone has different interests and different things that mean a lot to them. P and PA can whittle down the list of what you can and can't do. If people get enjoyment out of having wine with dinner, then they should be able to have that option, if they want it and can have it. Sometimes little things in life become big things when you are struck with a disease. Hanging on to those things can make a difference in your emotional well being, which is a big part of dealing with whatever it is you have, in MY opinion.

"Quality of life" is a biggie. And it's not only the disease that can adversely affect the quality of ones life, but oftentimes the treatments do, as well. I agree 100%, both in theory AND in practice, that diseases/disorders are, as you said, "very personal." As such, I personally resist a "one size fits all" approach to treatment.

For instance, I am a mom & nursing student, and I have always struggled with fatigue. As I've battled the MANY health problems I've had the misfortune to experience, a treatment that will result in MORE fatigue is always something that I try to avoid. Sometimes (such as recently, with the RSD diagnosis) I have no choice, but when there is an alternative, I'll take it. Personally, I'd prefer a painful treatment over one with drowsiness or "mental fog" as a potential side effect. But hey -- that's just ME, the individual, and I completely respect that not everyone would make that same choice; there are lots of folks who would rather avoid pain when/if they could. An increase in FATIGUE is the chief reason that I hope to avoid MTX. Fortunately my rheumy well understands the demands on a nursing student -- the amount of classroom & clinical study, research, and paperwork involved -- and has expressed his belief that MTX would not be the best treatment for someone in my unique situation; "YOU need to be able to study!!"

Hope I haven't offended anyone.
Not at all.

Giving you a standing 'O,'

[RichJ]

Mea Culpa! Mea Culpa! Guilty as charged! I said in my thread that, in addition to my other fears of MTX, I would like to enjoy my cocktails when I want them.

Regardless of my fears, I believe I that when there are acceptable medications out there that I can try, I should have the option. I should have a say so on what I take. Others may disagree and I respect that.

I researched and diagnosed my own P and PA last summer. My docs couldn't figure it out. They diagnosed me with all manner of other things. For a year, I've researched and read about medications. I believe you should participate in your plan or, at least, try. I may not have a choice, but I can fight for one and I intend to. I know my body better than anyone else. I also know my emotions and my state of mind better than anyone else. I'm glad many people have had success with MTX and I applaud that. I would prefer another option. I don't believe anyone should be called down for having a preference. These diseases are very personal, I've found. I own it and when you own something, you should have some say so.

Those are MY feelings and I hope they will be respected as I respect the feelings of others. I wouldn't begin to chastise someone for their choice. I will be happy to offer suggestions or advice or experiences or support.

Isn't that the way it should be?

I've found that these diseases take a lot away from the quality of life or can, anyway. Everyone has different interests and different things that mean a lot to them. P and PA can whittle down the list of what you can and can't do. If people get enjoyment out of having wine with dinner, then they should be able to have that option, if they want it and can have it. Sometimes little things in life become big things when you are struck with a disease. Hanging on to those things can make a difference in your emotional well being, which is a big part of dealing with whatever it is you have, in MY opinion.

Hope I haven't offended anyone.
hi caki,
well said. no one should be offended. it's your body and your chose to try what you want.

have a good night all

richard

ginger. im sorry to here that. i hope you can get some thing that will help

[jdeldrid]

One thought on "failing" MTX. A friend's rheumy once mentioned rather cryptically that she could prescribe it, and the insurance company could tell if she'd filled the scripts, but neither could tell if she'd actually taken the pills.

My friend (who has RA, not PA) "failed" MTX in two months.

[PJ Leary]

Ditto to jd,

There have been a time or two where I filled a script only to let it set in the cabinet until the proper amount of time went by so that we could move on to the next.

I can remember fighting years ago for coverage for celebrex, but had to work through lower classified ( ie less expensive dmards and nsaids ) before the insurance company would approve. I filled each and every one of them.

Food for thought....

[Caki]

What do you do about the P and PA while you are going through this process? Just hang in there with the break outs and pain?

[timothy41]

Sherry, saw your post and wanted to give a comment.

Not that this helps but is your insurance through an employer or direct? The thing everyone has to realize about health insurance is it is a “contract” it spells out what is covered etc. I hope you get the treatment you’re looking for but you have to “play the game” as Carly Simon says. Good luck and peace.