At Wits In Trying to get Enbrel

[cdelora]

I am a fairly new member and have never posted a New Tread before so here goes. I have been very impressed with members knowledge of P and PA. Hopefully you all can help. I have had P for over 20yrs and have tried various treatments. Mtx helped the most but now I need to get off it. Family Dr sent me to a Ruemy who has prescribed Enbrel. The problem is my prescription plan has a cap $2750 per year. Needless to say that will only last 2 mos not to mention other medications I am on. After 3 mos of hassel with the Ins co. (Sagamore) they have agreed to cover it under Major Med. The problem is that the pharmacies will not file
major medical paper work. I would have to pay for it ($1350 per month) and then file with the insurance co. They take 6mos or longer to process claims. I can't afford that. They will pay 90% if it is supplied in plan but they can not tell me were to go because the only self administered drug they are familiar with is insulin. HELP

[chaimFL]

Firstly, welcome to the board. :) Secondly, sorry to hear of the forth coming insurance woes. :( There is a web site www.needymeds.com (http://www.needymeds.com) that may beable to help. It's a slow process as well but it's an option to look into. Did your insurance not have a phrmacy recomendation that will file the major medical paperwork?? I'm sorry that I can't be that much of a help, but maybe someone else here has an idea.

[Allie]

Does your insurance company work with any "order by mail" prescription companies? Sometimes they can do more for you than the local pharmacies...

Just a thought, not sure if I am helping or just taking up space. Good luck!!

[Eve-Maridy_R]

Note from the Psoriasis Foundation Member Services Coordinator:

Remember! The Foundation has a Patient Advocacy department that can help you with these types of issues.

Please feel free to contact our Advocacy Coordinator, Joey Shearer, toll-free at 800.723.9166, ext. 407, or by email at jshearer@psoriasis.org.

We are here to help!

Sincerely,

Eve-Maridy Rice
Member Services Coordinator
erice@psoriasis.org

[PJ Leary]

Hi cdelora,

Welcome to the board. I assume you have an in network primary care physician. Make an appointment and ask him to oversee your routine enbrel treatment, including ordering and doing the injection training.

That gets you out of trouble with the pharmacy.

Another suggestion is for you to get in touch with the enbrel folks : 1-888-4enbrel. They will help you to sort out the insurance problems.

Let us know how you make out.

[cdelora]

GREAT NEWS A employee for the insurance adm just called and said that the higher ups finally figured out how to get the meds and have them paid for under major medical. Its is through a Home Health Care Service and they will even deliver the meds right to my door via a currier. The cost is a little less than through a Pharmacy. "Go Figure"
I really appreciate your advice and it is nice to know that there are so many freinds out there that are willing to help. Oh by the way my Ruemy and primary Drs will not order or administer this drug because of liability.
I do believe it is time to change Derm Dr of 20yrs because I am not happy that he would not or did not prescribe Enbrel.

Well for now thanks again:p

[PJ Leary]

Hi cad,

Good for you! It is amazing what we can get through insurance if we are persistant. Excellent job! We may need to keep you around to help out those newbie advocacy guys at NPF;) . ( No offense, Joe & Bob )

I never thought of the home health option, and will keep it in mind for future reference.

I look forward to your participation on the board.:cool: