Insurance Coverage for Tecfidera

[cmgingras]

I am in crunch time trying to find a provider who covers Tecfidera but NONE of the major insurance providers have it listed (even on platinum plans) on their formulary. My doctor said that they will initially deny the med but after an appeal (because I have tried several other therapies that were not helpful) they will approve it. I was hoping for feedback from others who have gotten this very expensive medication covered. I am shopping for an individual plan and don't work for a large company where I could get group health insurance. Anyone in a similar situation who knows which insurance carriers do cover it (even with going through the appeal) the insurance carriers name and even the plan name would be very helpful.

[gouletmommy]

Check out tecfidera.com They have a $10 co-pay program. My co-pay per month was $10 monthly co-pay through tecfidera. There are some restrictions but you can call them directly and they can walk you through it.

[Marco]

I am unaware of any ACA marketplace plans that cover Tecfidera. In many (but not all) cases the exact same drug formulary is used for bronze through platinum plans in a particular market and carrier.

I would call MS ActiveSource @ 1.800.456.2255 and see if they can point you in the right direction. They have insurance and benefits specialists that may be able to help you. They also have patient assistance programs that may help you.

I would call an independent insurance agent in your area and have them do some of the leg work. Most of them offer their services "free to you" and are paid by the insurance company if you sign with them. This works as an incentive for them to find a plan you will actually buy.

Please let us know what you find out. I am sure you are not the last person that will go through this exact same scenario.

[Marco]

I finally found Tecfidera on the special forumulary for BCBS Texas. Tecfidera is listed as a Tier5 drug if your plan takes that into consideration..

http://www.bcbstx.com/pdf/specialty_druglist.pdf

The 1 platinum and 20 gold plans that I was offered did NOT have tecfidera listed, but a BCBS-TX Bronze plan did.

[football-mom]

United Healthcare covers it. They actually even recommended it to me. They took Rebif off their formulary and recommended Tec or Copaxone in its place. Weird.

[OrangeMetal]

Great research Marco. I have been wondering about this myself. I am currently uninsured in New York. Do you have to dig in every plan to find out if Tec is covered? Can a plan make you try another drug and come back? That would not be good for me as I've only been on Tec since May and it works well for me. Can a dr write a letter on your behalf?

I am wondering about those of you on the Tec patient assistance program and if anyone has renewed it for a second year yet. Maybe I should post this to a new thread.

[OrangeMetal]

to football mom - tecfidera - united

Hi Football Mom,
Wait, United covers Tecfidera? I thought I heard they were the one agency that didn't cover it (Biogen had told me that). Did they change their policy? Are you going through with it?

[football-mom]

My tec just came in the mail today and I'm NERVOUS about starting it. The copay on my plan is $100, but I did the $10 plan with Biogen. Yes, UHC has been sending me mail for the past 2-3 months warning me that the Rebif I was on was being taken off the formulary.

[football-mom]

I should add that my plan is through work, not an ACA plan.

[hope32]

Our plan is through DH's work. As of Jan 1 we have a Highmark BCBS plan and Tec is listed on the formulary.

[laurasari]

I just got off Emblem. gHI. And they covered Tecfidera. I am now Pilgrim Health and its a tier 4. But they cover it. Outside Ma I think they are United Health. I am getting preauth now so let's see what happens I have been on many and Dr said this was my last choice I have been on it since June with no significant side effects