Insurance appeals

[hallk33]

I was recently diagnosed with RRMS. I decided that I wanted to do Gileyna as my first DMT. I have Humana Access for my insurance. We looked up what the different medications would cost us and they all have the same copay. There was no mention on any restrictions. My insurance rejected Gileyna because of the cost. They want me to fail Copaxone and another injection before they will cover Gileyna.*

I chose Gileyna mainly because of the lower overall side effects, increased convenience and I found that the overall effectiveness of the drugs I was considering (Rebif, Copaxone, Gilenya, and Avonex) were about the same. My husband is afraid of needles and I would need his help with injections. I tend to get rashes on my legs so I frequently wouldn't be able to do injections there. My mom is taking interfons (not for MS) and has had a lot of bad side effects from them. I'm concerned that the same thing would happen to me.*

I can still appeal. I believe that my doctor already has and was rejected. I was supposed to start the medication in a week and a half. I know even if I decide not to appeal and chose a different DMT that it will still be a few weeks before I can start.*

So I would really prefer to avoid the injections but I don't know if I want to delay starting treatment for what could be months. How long did your appeals take? Do you have any tips for a successful appeal? I posted this in the general forum area because I am wondering about insurance appeals in general not necessarily just for Gilenya. If I have posted in the wrong area then I will gladly move my thread.

[heliotrope]

The insurance has a specific reason for rejecting your claim. You need to find out what that is before you can have any hope of making a successful appeal. Ask for a copy of the policy used to reject the claim (the number is probably in the rejection letter). You'll need to address the policy - and its relationship to you - in making your appeal. You cannot claim that the policy is wrong. In accepting your insurance, you've probably already agreed to it (though I'm not sure what the actual legal status is - but if you don't hire a lawyer, this will cause them to ignore you). You need to explain how the policy is being incorrectly applied in your case. If your state has a healthcare advocate, you might want to talk to them. Good luck!

[Redwings]

Under the Gilenya Go Program, Novartis offers assistance with prior-authorization requests and appeals. They've probably dealt with Humana before. Maybe they can help. 1-800-GILENYA (1-800-445-3692).

[onlyairfare]

Although the co-pays are all the same for you as a patient, for Humana the Gilenya costs more so they want you to try the cheaper (for them) medicines first. Insurers do not necessarily admit that the issue is cost, but it sounds as though they have told you that directly. Usually they call it "tiered therapy."

As mentioned, look at the specifics of the policy and why they want/require you to try the others and fail first. If there is any good reason why you can't do Copaxone or another injectable (allergy, inability to give yourself shots, maybe a severe phobia if not a physical inability to do so) use that. If there are features of your case of MS that make Gilenya a better choice, use those, and explain, or have your doctor explain, that failure to use the best medicine for you can result in irreversible neurological damage, for which the insurer would be responsible.

Maybe your mother's allergy to interferons has a hereditary base and you don't want to take the (high) risk of a severe reaction your self.

Yes you can still appeal, and you should do so. Exhaust the insurer's internal appeals process, and then proceed on to the next level if necessary. sometimes this is an administrative law judge if it is a Medicare-related policy, sometimes it is an employer appeal if the policy is through work, and sometimes it is through the state insurance commissioner or managed care department if that is how your state's laws work.

You can always try a political appeal too - call your senator's office and ask for help from his/her legislative assistant for health care matters.

[hallk33]

The rejection letter says "The benefit provides coverage for the requested drug when medically necessary." According to them it isn't medically necessary until I have had Copaxone and Avonex or Rebif and those medications were ineffective or I'm intolerant to them.

My policy says that any of the MS medications are covered so long as I'm only on one DMT at a time and the prescribing doctor completes the pre-authorization request. My doctor submitted the pre-authorization request and this is when I got the rejection letter.

I talked to my Gileyna Go program coordinator last week and she said that my insurance was having difficulty finding a pharmacy to dispense my medication. There is no mention of this in the rejection letter. I don't understand why my insurance would start looking for a pharmacy if they were going to reject me.

[KyleW]

Part of this could just be Humana. They're pretty awful. Every time I submit an out of network claim, with paid in full receipts and the "Pay Provider" box entirely unchecked, they sent the check to the provider. This adds 2 weeks to the process for no reason!

[hallk33]

I also am wondering if it has anything to do with the fact that I'm $12 away from hitting the max out of pocket. Once I hit this almost everything will be 100% paid by Humana. I should have already hit the max out of pocket but it appears like some claims are disappearing and then are in review again. I have noticed that lately my claims have been taking a lot longer to process.

My insurance may also be auditing me. They sent me a letter saying they were auditing me because they thought that I had alternate insurance. I don't. I was told that this was closed but then when I called to discuss why a claim was being doubled billed I was told that I was still being audited because they think that I qualify for Medicaid which I don't.

It all seems like suspicious timing. I'm frustrated by all this and I just want to get on medication as soon as possible.

[heliotrope]

Time to call in the healthcare advocate. This is more than a simple policy rejection - you need outside help.

[hallk33]

How do I get in contact with a healthcare advocate? The rejection letter included a list of independent review organizations certified in Wisconsin but I don't think that is the same thing you are talking about. I really don't how what advocates do, how do you think they could help in this situation?

[empirerecs]

Hi - another reason they will deny Gilenya is because they need you to try the more "tried and true" medications. Gilenya is still new to them, they don't like new drugs AT ALL. I have BC/BS and had to have the G authorized and the neuro had to prove that I had taken Betaseron even though they had claims for it. duh. Humana is probably the most difficult insurance company, for their insureds and the medical providers, they make you jump through a lot of hoops.

Caremark pharmaceuticals ships the Gilenya to me, they ship nationally. They are great, I wasn't aware you could even get Gilenya at a local pharmacy.

So, it may not be just the cost. They will do the same thing for most experimental and fairly new drugs, it really doesn't matter the cost. The Betaseron was almost the same cost! I still can't believe interferon is so expensive.

I hate needles, I have to have extra sedation when I get an IV and thought I would not be able to do the shots. Surprisingly, I did them. The injector really helps, it's quick and easy to do on your own. My nurse told me to use tape to hold the injector down when I did my arms and hips so I would only have to press the button (that makes sense if you can see the injector). The Betaseron really worked for me, we stopped because I have major depression and interferon can increase that in some people. If I have problems with the Gilenya, so far so good, I will go back to the Betaseron.

good luck, such an infuriating situation.

[heliotrope]

How do I get in contact with a healthcare advocate? The rejection letter included a list of independent review organizations certified in Wisconsin but I don't think that is the same thing you are talking about. I really don't how what advocates do, how do you think they could help in this situation?

My state has a slightly different - and more involved - program. Here's WI's equivalent: http://www.dhs.wisconsin.gov/guide/spec/probins.htm. Also, put in a call to your state rep.