Insurance

[Westgrl]

I am curious to see how insurance companies cover this to start. I have heard some are covering it right away but my current insurance basically told me that it's not in their 2014 formulary & they can't say if it will be covered in 2015.

I called Biogen about financial assistance & they basically said that they would have to wait & see what happens when I apply & then made the comment that some people may just need to stay on Avonex until it's covered. That concerned me a little.

My Dr office is faxing the form over today and I guess I will wait & see. Would really be interested to see how everyone else is coming along with approval/denials!

[Ciel]

Insurance

My doctor sent a letter of medical necessity with the original prescription and the pharmacist handled contacting insurance. It took only 24 hours to get approval. I did go off Avonex in advance and the doc said in the letter I did tolerate it well. Also, I enrolled in the observational study. I think your neuro has to be aproved for that. That may have helped. In order to get financial assistance for the copay I just called Biogen at 800-456-2255 and they handled it over the phone. I hope you are able to get it worked out. The biggest problem I had was that Caremark lost the original prescription so it has taken longer to receive the started kit than I had expected

[Westgrl]

I was getting copay assistance for Avonex. Fortunately, since it's the same company, all of that is pretty much the same.

I got a call from them today confirming my information and letting me know they were in the process of contacting my insurance company. *crossing fingers*

[sos219]

I e-mailed my insurance company in October, they weren't positive on how it was going to be handle but said the it was going to be a non preferred drug, and that there was going to have to be prior authorization stating which previous therapies have been tried and failed (so like step therapy) I know for my Insurance Gilenya requires trying at least 1 other drug for step therapy and Betaseron, and Aubagio require 2 different failed meds. So I'm nervous to see there Plegridy will fall.

[Westgrl]

Nothing yet. I went for my appt with my neuro yesterday and he didn't seem to have any notes about them having to submit anything additional. Not sure if this means they are trying to completely deny it & Biogen is trying to work with them or what. Nerve wracking.

[sos219]

MS active source called on this Monday to verify all of my information that was on the start from. They said that I will be getting a phone call from my pharmacy with in 4-7 business days to schedule delivery and go over copay information. I don't know if this means that my insurance has approved it already.

I think it's been said before but they did verify that they have a co-pay assistance program as well just to call them after I talk to the pharmacy but BEFORE I schedule the first delivery.

All of this waiting is the worst part. :-(

[Westgrl]

I'm a little annoyed. I called a couple days ago & spoke with someone who assured me that the pharmacy had my prescription, my copay was $60 for a 30 day supply but if I needed assistance they would process me for that. I also received the welcome kit in the mail.

Today I got a call that my insurance was verified, no prior authorization needed, he offered to transfer me over to start the copay assistance & then the girl there told me there is no help for copays currently with Plegridy but possibly they will soon. I mentioned that their website clearly states they offer $0 copay assistance and is it something they will have in place soon & she said most likely. She gave me the option of waiting to start or paying the copay & I opted to pay. She told me I could call back at a later time to check on the copay assistance & in the meantime they would call the pharmacy to give the ok to schedule.

I'm just really irritated that the Plegridy website states they are offering assistance, the last girl I spoke with said they would process me for it & now I am told it's not available. Has anyone else received assistance? If so, I am calling them back to speak to someone else.

[Marco]

I would just call back and ask the same question again. Some times the agents aren't as familiar with a new financial program. I also would never demonstrate my ability to pay, until the copay assistance program was in place. There's just no reason for them to get extra money from you.

So please call back and ask them to put you on the $0 copay program and refund your money. Of course, the pharmacy may have taken your money so Biogen may not be fully aware. If the copay assistance program is NOT available, then they should remove the program from their website - AND - still refund your money for their mistake.

[sos219]

I just got a call from my insurance company saying they are denying my claim. She couldn't tell me why she had no idea.

I'm mad that it's denied but even more so that they had someone call me with no usable information. I just want a reason. Just tell me WHY and I can work with that.

I guess now my Doctor either appeals it or I choose a different med? :-(

I'm just really irritated that the Plegridy website states they are offering assistance, the last girl I spoke with said they would process me for it & now I am told it's not available. Has anyone else received assistance? If so, I am calling them back to speak to someone else.

I haven't received assistance but I was told that there is definitely supposed to some. I would call the back and ask to speak to someone else.

[Westgrl]

Marco - I am going to call again today. The girl I spoke with was from Biogen and I haven't paid any money to the pharmacy yet. My previous experience with this with Avonex was much easier so I am hoping I just got a girl who didn't know what she was talking about.

Sos - I'm sorry I would call your doctor. I know some are able to get it approved when their doctor appeals or submits a letter stating this is medically necessary. It is horrible that they couldn't give you a reason why! Keep me posted on what happens!

[Westgrl]

Good news... I called back this morning & they enrolled me in the $0 copay assistance program. No issues or arguments. I think the girl I spoke with last night just had no clue. They said I should get a call from the pharmacy in a few days to schedule.

[Marco]

Westgrl - good news. I'm sorry you had gotten incorrect information, but so glad it is working out for you. Biogen is normally very supportive of new therapies, especially with offering patients co-pay assistance. For many years, I worked in the computer industry and have called countless support lines. There are times when you just have to politely get off the phone, and call back to talk to someone else. Again, I'm glad it worked out.

SOS - the drug is still new and probably still not on your insurance plans drug formulary. I can tell you it's probably NOT worth going to another medication for 1-2 months, before trying to switch back to Plegridy. I would have your doctor appeal their decision and hopefully he will prevail. You can also call back and talk to someone else, give them the case number from your documents and the information should be in your file.

This disease is hard enough without having to maneuver around a few bad eggs and a goofy process, but you both are strong enough to do so. BTW, it's often worth the extra hassles to get what you want! I wish you both well!!!

[sos219]

My road to Pegridy is blocked for now I think... I got my Denial letter from Univera in the mail. In order for them to cover Plegridy I have to have tried and failed ALL the MS meds that are on the formulary. Avonex, Copaxone, Rebif, AND tecfidera!

They also state that I have had an intolerance to copaxone ( I've never even been on it) and that I am in a "trial" with avonex and have not yet failed it.

I don't meet the the criteria for them to pay for this drug.

So that's it I'm staying on Avonex. No drug is 100% effective and 2 new lesions are better than 10 new lesions. So maybe it's working and the Idiot PA was just jumping the gun with telling me to switch....

Good Luck with Plegridy I hope it works well for everyone that can get it.