Remicade Appeal Drama Conclusion

[rosee_posey]

So, get this -

Freeken BCBS.....

So, I get this call from BCBS while I'm sleepin' (I've got a flare, whadaya expect) and they tell me that "everything is all set for Friday" - at least that's what I thought they said - and I breathed a sigh of relief , and called the doctors to say that I was approved for Remicade, and rolled over back to sleep.

Then I get a call from the Rheumy's office.

"You've been approved for Enbrel."
"What?!"
"That Dermy guy's letter - said either Remicade or Enbrel, so they decided to give you Enbrel."
"MOTHER$#@!"

at this point, we began to talk logistics - pharmacy, etc.

OK - at this point,
I know that Enbrel is approved for Psoriatic Arthritis and Remicade is not.
I know that Enbrel and Remicade work using the same anti-TNF.
So, the theory goes, this should work.

Meanwhile, I know that Enbrel and Remicade cost the same amount. I know that Remicade has always worked - and the last thing I want to try is something new, but hey, beggars can't be choosers, right? I'm really angry that an insurance company can dictate the type of medication that I receive. This is really pissing me off.

(Rose has thought) Hmmm.

I just realized something - Enbrel would come under my DRUG plan, and Remicade would come under my MEDICAL plan...mother macree, could that be it?! In a court of law, I suppose they could use the "Remicade is not approved for Psoriatic Arthritis" bit, but I bet this their out.

Let me think about this some more, and I'll post a nice organized blurb about my lessons learned. Wait for it - you'll want to print it and keep it for your use later on.

Thanks for listening,
- rose

[bella247]

Hey lovely,

Good luck with all the battles, but be strong, and as stupid as it sounds don't stress out.

Take care and smile

Bella

[tvcats]

Rose, I'm thinking about ya.
Funny thing -- we're supposed to avoid stress & then look what the folks who are supposed to help keep us healthy put us through. Unbelievable.

[Chikara]

There should be no reason why your insurance company can deny Remicade. You're not using it for psoratic arthritis, you're going to be using it to stop a life-threatening flare. You asked for approval for Remicade, not Enbrel.

Insurance compaines have no medical expertise and do not have the right to reccomend any alternative medical treatments for you, that should include any medications that could potentially effect your condition in any way.

I think you should call a lawyer. That should scare BCBS into shape.

[MikeK]

Oh Rosee!

I'm so very sorry about all of this! :( :mad: It make me very angry to think that all of this could have been avoided. It's no wonder why people hate insurance companies. I hope that this nightmare has a positive outcome.

Feel better. Good luck and please keep us posted.

Mike

[Kimbercat]

Rose:

I know what you mean about BCBS. I have them too, and have had several go-rounds with them, stressing me out so that I need more drugs! :confused:

Fight for what you and your derm believe is the best choice for you, and if you need help, contact one of the advocates here at NPF for help. I have personally met Robert Gassner, and he seems like a very caring person who is willing to go to bat for us when we need someone who's been around the block.

Good luck, and stay strong!

[chaimFL]

Are you going to start Enbrel? I know it's not your first choice, but it will help. It might take you using Enbrel to get Remicade. If the Enbrel doesn't work, you have something to go back with.

[Allie]

Rose -

Okay postive thoughts..... You are getting to try a new drug and see if you have options for future use, and if not then you have a bigger stick to fight you battle with!

I wish you luck on Enbrel. I have heard marvelous things about it & I wish you lots of luck!