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Insurance company denied Gilenya

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    Insurance company denied Gilenya

    For the first time my insurance company has denied coverage for a DMD. I have BC/BS of Louisiana.

    Has anyone else had this problem with their insurance company?

    Did your Neuro appeal and finally get you approved?

    I'm at a loss here. I've stopped my other DMD waiting to start Gilenya.
    Dx'd 4/1/11. First symptoms in 2001. Avonex 4/11, Copaxone 5/12, Tecfidera 4/13 Gilenya 4/14-10/14 Currently on no DMT's, Started Aubagio 9/21/15. Back on Avonex 10/15

    It's hard to beat a person that never gives up.
    Babe Ruth

    #2
    Hi Waydwnsouth,

    My MS Specialist has gone through the appeal process for me, but it wasn't for Gilenya. It was over three years ago when he submitted a lengthy letter to my insurance company on my behalf. My insurance company then approved it.

    He's well-versed on all the points that must be made and does have plenty of experience writing these types of letters. He recently commented that with all the changes in healthcare coverage, he now has to write them more and more. Unfortunately, that also cuts into the time he could otherwise devote to his patients. He also said many times the only way to get things approved is by threatening legal action.

    Since you've already tried two other injectables and Tecfidera without any success (and can't take Tysabri because you are JCV+), seems like in terms of efficacy, Gilenya would be the only other reasonable option for you. Hopefully your neuro is also familiar with the jargon that must used in order to get approval.

    Please keep us posted.

    Best of luck ,
    Kimba

    “When you change the way you look at things, the things you look at change.” ― Max Planck

    Comment


      #3
      It is likely that you can appeal this- you´ve already tried an injectable and "failed." Please pursue this. Know that many ins. companies just got fined millions of $ for refusing to cover procedures and drugs that they were obligated to cover. Be a thorn!

      Comment


        #4
        How long do these appeals normally take?
        Dx'd 4/1/11. First symptoms in 2001. Avonex 4/11, Copaxone 5/12, Tecfidera 4/13 Gilenya 4/14-10/14 Currently on no DMT's, Started Aubagio 9/21/15. Back on Avonex 10/15

        It's hard to beat a person that never gives up.
        Babe Ruth

        Comment


          #5
          I was denied for Gilenya the first time it was prescribed. I have BC/BS TX. I had to go on Avonex for a while and fail before they would approve it. I had already failed on Copaxone. Sorry you are going through this and I hope they get it fixed soon.

          Comment


            #6
            Originally posted by Waydwnsouth1 View Post
            How long do these appeals normally take?
            Sorry, I wish I could remember how long it took, but I can't. I also know each insurance company is different at how long they take to approve things, and I'm sure the appeal process is the same.

            You would get better information by asking your neurologist if he's dealt with any appeals to them in the past and calling your insurance company (multiple times to learn where it is in the process). I always get more accurate information when I call my insurance company myself.

            Best of luck ,
            Kimba

            “When you change the way you look at things, the things you look at change.” ― Max Planck

            Comment


              #7
              My appeal only took about 1 month maybe 2 but I had been on it for 3 years previously as part of the study and my previous insurance company.
              Rise up this mornin, Smiled with the risin sun, Three little birds Pitch by my doorstep Singin sweet songs Of melodies pure and true, Sayin, (this is my message to you-ou-ou

              Comment


                #8
                I am awaiting results of my appeal. It was filed a month ago. My neurologist always has to fight for Gilenya. Good luck!
                Diagnosed with RRMS on 3/15/2013...beware the ides of March!
                Rebif from 5/2013 - 09/2014.
                Gilenya since 11/2014.
                Also taking vitamin D3, fish oil, magnesium, and B12.
                EDSS 3.

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