Tecfidera - Insurance Rejected

[jersey4ever]

So, I have had a pretty bad 9 month try of Copaxone - 3 enhancing lesions over 2 MRI's - 1 relapse. My neuro wants to switch me to Tecfidera and said none of other crab drugs is worth trying...but despite 2 appeals my insurance will not approve Tec unless I have "failed" 2 other drugs...so they are basicaly saying "Go try a drug for 6 months and hope you get really sick - then we will give you Tec"

Anyone else faced this? How did you fight it? What should I do?

[tspaulding]

So, I have had a pretty bad 9 month try of Copaxone - 3 enhancing lesions over 2 MRI's - 1 relapse. My neuro wants to switch me to Tecfidera and said none of other crab drugs is worth trying...but despite 2 appeals my insurance will not approve Tec unless I have "failed" 2 other drugs...so they are basicaly saying "Go try a drug for 6 months and hope you get really sick - then we will give you Tec"

Anyone else faced this? How did you fight it? What should I do?

So sorry this happened to you. I was on copax back in 99 for 2 yrs then on Gilenya for past two yrs. I did not have a problem w/ insurance so sorry for you.

I would speak to neuro about meds again since copax is not an interferon. Good luck and I hope you are able to take tec soon.

RRMS 1995, age 21

[KitOP]

Have you contacted Biogen directly for assistance with the drug? They do have a program although I'm not sure what the criteria may be.

Good luck!

[disabled dreamer]

I had a similar problem with my insurance. I was Avonex first, then Tysabri but they denied both Gilenya and Tecfidera because I had not been on 2 of the CRABs, they prefer C by the way.

I had one neuro office working on G and another working on Tec, figured whichever was approved first. Both appeals were denied and I was in process of second appeals when I spoke with Biogen and now am on their program to get Tec for free for a year.

I had to tell my neuro about this program, but after that I was taking the med within a week.

Hope you can find a solution as well, just remember that we have to be our own advocates and fight. Sad and tiring but true.

[Marco]

Call 1.800.456.2255 and ask to speak with an insurance specialist. You'll need to provide them your health insurance information and any denial information (claim#, date, etc). Emphasize that both you and your neurologist want you on Tecfidera and ONLY your insurance denial and the cost is preventing you from taken it.

They'll need about a week to sort things out and let you know what they can do for you.

While you have the first operator on the phone you might as well request your "Free MS exercise DVDs" for your hassles.

[Goldfinch]

What should you do? Aks yourself why your neuro is dismissing the other CRABs out of hand without at least a trial run. Be your own advocate, get educated, don't be anyone's guinea pig.

I tried Avonex for four years. When that decreased in efficacy and I started having more severe relapses more frequently, I switched to Tysabri. My insurance did not play waiting games with me, fortunately, and I have a neuro that does not subscribe to the wait and see approach. He treats aggressively. That said, I am now switching from Tysabri after having been on it for 72 infusions and testing positive for JC virus. My neuro informs me my next best bet is Gilenya.

So...since Copaxone uses a decoy mechanism to treat your MS, and the other CRABs use a different method, why is he so adamantly opposed to trying a different mechanism? Give one of them a shot against your neuro's advice. It is only 6 months, the drugs use a different mechanism than Copaxone, and there is no guarantee Tecfidera will work any better than any other medication out there. In fact, at this point, statistically I would say you have as much of a chance of any other drug working better than Copaxone. Whether you try Avonex, Rebif, Betaseron, or Tecfidera, it's all a crap shoot.

[JBWInColorado]

Call the tecfidera assistance line. Same thing happened to me - insurance rejected - and in a 10 minute phone call I was hooked up with free Tec for a year. They WANT you to take their drug and WILL get you on it. I'd never even tried another drug - just recently diagnosed and they didn't hesitate to hook me up for free.

[disabled dreamer]

What should you do? Aks yourself why your neuro is dismissing the other CRABs out of hand without at least a trial run. Be your own advocate, get educated, don't be anyone's guinea pig.

I tried Avonex for four years. When that decreased in efficacy and I started having more severe relapses more frequently, I switched to Tysabri. My insurance did not play waiting games with me, fortunately, and I have a neuro that does not subscribe to the wait and see approach. He treats aggressively. That said, I am now switching from Tysabri after having been on it for 72 infusions and testing positive for JC virus. My neuro informs me my next best bet is Gilenya.

So...since Copaxone uses a decoy mechanism to treat your MS, and the other CRABs use a different method, why is he so adamantly opposed to trying a different mechanism? Give one of them a shot against your neuro's advice. It is only 6 months, the drugs use a different mechanism than Copaxone, and there is no guarantee Tecfidera will work any better than any other medication out there. In fact, at this point, statistically I would say you have as much of a chance of any other drug working better than Copaxone. Whether you try Avonex, Rebif, Betaseron, or Tecfidera, it's all a crap shoot.

My purely educated guess would be because the CRABs, i.e. Copaxone, Rebif, Avonex, and Betaseron, have all shown to have around the same rate of slowing down disease progression.

Jersey's MS is getting worse so neuro likely thinks need something more effective. Tysabri, Gilenya, and Tecfidera have shown to be more effective in clinical trials, and are the only FDA approved MS treatments shown to be at this time. Ty being most effective, with G and Tec about the same both falling between the CRABs and Ty.

There are now more effective therapies with safer side effect profiles. Still lots of side effects but GI disturbances and flushing are considered safer than liver, kidney, etc. issues known to be caused by the CRAB injections.

That being said, I do agree that MS is such a variable it is all, as you say, a crap shoot. We all play the odds we are personally comfortable with and hope to break even until a cure allows us to win.

[hope32]

I'm sorry that happened to you! I had already been on Copax and then Beta in the past so maybe that's why my ins didn't give me a hard time. (They've given me a hard time about much lesser drugs for unknown reasons!)

And my preference would also be trying Tec rather than an interferon. I do not miss injections or flu-like symptoms at all, and I am excited about Tec's apparent increase effectiveness compared to the CRAB drugs. I hope Biogen is able to help you! Keep us posted!

[jersey4ever]

So...

...yes they offered to hook me up free for a year - but so what - aren't I just going to have to go off of it in a year when my insurance still denies it? Doesn't that seem worse - trying it for a year and then having to stop taking it?

[PhiSiggyro]

I took tysabri for about 4.5 years for free from Biogen cause my insurance didn't cover it. So they could give it to you for longer then year

[Temagami]

Every year each ins. co. has to decide which drugs they will offer and at what tier of the formulary. It´d be worth taking it and hoping that the formulary changes in your favor. Who knows, in a year, Tec could look cheap compared to some new DMD.

[billp]

CBC Shows Low Count

Blue Cross FEP requires lymphocyte count at or above 910 cells per microliter to grant prior approval for coverage under their specialty pharmacy program. I have been averaging about 900 cells from my last 3 CBCs and will get another blood test in a couple of weeks. Anyone out there with a similar problem? I am currently not on any of the DMDs, although I injected Avonex for 13 yrs.

[jersey4ever]

APPROVED!

After 5 rejections - I actually got my companies benefits and HR department involved (luckily I work for a big company!) and all the sudden my rejection was under review again and they requested more information from my doctor...then I got an APPROVAL...

...just another example of don't give up - keep fighting!

[hope32]

That's great! I'm so happy for you and glad your persistence paid off. Good for you!