Rheumatoid Arthritis Support Group
Rheumatoid arthritis is a chronic, inflammatory, multisystem, autoimmune disorder. It is a disabling and painful condition which can lead to substantial loss of mobility due to pain and joint destruction. The disease is also systemic in that it often also affects many extra-articular tissues throughout the body including the skin, blood vessels, heart, lungs, and...
For a brief recap to start -
At my last appointment in November, since I had new insurance I had the doc write an Rx for Humira - I had been receiving it for free thanks to the Abvie Foundation prior.
Received a denial letter which said that I had to try Enbrel first. After 2 phone calls and a letter directly to the doc I had no response at all about the denial letter and about getting a pre-authoriztion for Enbrel. I had taken my last injection of Humira in the middle of December and have been going downhill since. To say I was upset about all this is being nice......
Doc came in and the first thing he asked is why I wasn't still taking Humira. So I told him the story, and he became flustered for a lack of a better term. He had not received my letter (never made it from the office to him) and said there was no excuse for the office staff to not return my phone calls. That being said, he was more upset about how the insurance companies try to dictate what he does. This doc is one of the heads of a huge arthritis research center. As I have seen in the past he is so focused on the science of the disease he doesn't realize what happens in the office. His point was that the Humira was working for me and should not have to change just because an insurance company says so.
Instead of dwelling on what happened, he immediately wrote me an Rx for 1 year worth of Enbrel plus my other regulars of Methotrexate, Folic Acid, and Prednisone.
Well I get home and call the insurance company since I didn't know what to do with the written Rx. The rep was very nice to me, and started by looking up Enbrel to see that it was covered. Yes, it is in fact covered, but needs a pre-authorization. I told her about the denial letter about the Humira which stated that Enbrel was OK, but that didn't matter. Now....only the doctor's office can call for this pre-authorization.....oh boy....here we go again. So I take a deep breath and call. I spoke to a girl who sounded very knowledgeable about these things, and took down all the info. She asked to give her a couple days.......
Man oh man - I know I am not the only one having problems like this - I've seen quite a few posts in the past weeks with similar problems.
It isn't over 'till it's over........
At my last appointment in November, since I had new insurance I had the doc write an Rx for Humira - I had been receiving it for free thanks to the Abvie Foundation prior.
Received a denial letter which said that I had to try Enbrel first. After 2 phone calls and a letter directly to the doc I had no response at all about the denial letter and about getting a pre-authoriztion for Enbrel. I had taken my last injection of Humira in the middle of December and have been going downhill since. To say I was upset about all this is being nice......
Doc came in and the first thing he asked is why I wasn't still taking Humira. So I told him the story, and he became flustered for a lack of a better term. He had not received my letter (never made it from the office to him) and said there was no excuse for the office staff to not return my phone calls. That being said, he was more upset about how the insurance companies try to dictate what he does. This doc is one of the heads of a huge arthritis research center. As I have seen in the past he is so focused on the science of the disease he doesn't realize what happens in the office. His point was that the Humira was working for me and should not have to change just because an insurance company says so.
Instead of dwelling on what happened, he immediately wrote me an Rx for 1 year worth of Enbrel plus my other regulars of Methotrexate, Folic Acid, and Prednisone.
Well I get home and call the insurance company since I didn't know what to do with the written Rx. The rep was very nice to me, and started by looking up Enbrel to see that it was covered. Yes, it is in fact covered, but needs a pre-authorization. I told her about the denial letter about the Humira which stated that Enbrel was OK, but that didn't matter. Now....only the doctor's office can call for this pre-authorization.....oh boy....here we go again. So I take a deep breath and call. I spoke to a girl who sounded very knowledgeable about these things, and took down all the info. She asked to give her a couple days.......
Man oh man - I know I am not the only one having problems like this - I've seen quite a few posts in the past weeks with similar problems.
It isn't over 'till it's over........
I'm thinking there will be.
Allowing a patients RA to flare do to lack of response is neglectful.
I'm betting your doctor was more then a little upset.
Thinking here you could not have been the only patient.
Let us know how it goes.
Sammy
Received the authorization approval in the mail today - a step in the right direction! At least the girl I spoke to in the office last Thursday did her part.
So I call my insurance company to see what the next step is. Everyone I have spoken to at this company has always been so pleasant and helpful - didn't even get put on hold after navigating the menu system!
I was told that it has to be fulfilled through a specialty pharmacy which I already knew after reading up on things like this here. The rep then transferred my call directly to Accredo the specialty pharmacy.
The Accredo rep had my information on her screen which included my authorization from the insurance company. Good! When I told her I had a written Rx (actually computer generated), she said I had to either mail it in or have the doc's office fax it to them. I told her I would mail it in as if I call the doc's office it will likely not be done.
So out in the mail it goes tomorrow - then another period of holding my breath again. There was no mention yet about any co-pay, but I am sure that will be addressed when I get a call from them for delivery arrangements. I've already registered with Enbrel assistance, so hopefully that will automatically kick in.
This authorization is good for 6 months, so I guess I'll have to go through all this again soon enough.
Anyway, I thought I would post an update. Thank you all again for all your support!
Coaltrain, I'm so glad you got your pre-auth stuff settled. I am FLOORED that insurance can require that you take a different med first when the doc writes you a prescription! :thud: Especially when you've been on it and it was working!
I'm beginning to dread my first appointment March 21. I have been going through all my lectures from school and pulling every one that had anything to do with inflammation (there were many) into one folder to start changing my nutrition (which has been excellent, but included dairy, for example, which is inflammatory and lots of tomatoes, peppers and eggplant which are nightshades and, thus, inflammatory. Am also reading Clean Cuisine: An 8-week Anti-Inflammatory Nutrition Program written by Ivy and Andrew Larsen, MD. I sooooo don't want to get into the insurance hassles. I really don't want to take biologics. So, one day at a time is my new motto.
Thanks for sharing your experience, Coaltrain, and I wish you all the best now that you're back on track. Your persistence is inspirational! Blessings!
Same mail order I go through for my Orencia.
I have to provide them with the info once I receive it for the co pay assistance.
Wishing you the best of luck with Enbrel.
Sammy
I took my last Humira injection the second week of December. I was kind of anxious about having a sudden effect, but I didn't. I noticed a slight decline once about every 2 weeks.
Now 11 weeks later, I can say for sure that it has totally worn off and I am back to where I was last winter as far as immobility and pain. Yesterday it was my right ankle - today my right hip. Very difficult to walk even with my cane. And man, does it hurt!
I guess it has put me in kind of a bad mood also as this whole thing has been so frustrating. I would love to have that office girl who let me drop through the cracks see me this weekend.......
I jumped through many hoops to get the Humira in the first place, then it took 4 months to feel any positive effect. Now back to square one again.
Sorry for the seemingly depressing post - actually I am keeping positive knowing that I should have some Enbrel in hand within the next week or so.
When I was on the Humira, I guess because the positive effect came on gradually, I didn't realize just how much it was helping me. I certainly know now!!
Coaltrain
we can stand on the square together but I only have my neck to blame.
My last injection of Orencia was the end of December.
I am scheduled to re-start with Orencia infusions sometime mid April to load me more aggresively says the rheumie
Then I'll switch back to orencia by injections January 1 when the co-insurance will have to be satisfied again.
I have a habit of perhaps discounting the gradual and moderate changes that injections from orencia offered. not now. ALL the pain and immobility (to use your words) is the same as the worse flares in all the past years. yeah, the breaks in treatment suck and since I don't take prednisone they suck even more.
in empathy :)
hang in there coaltrain! the enbrel is close. let's have a shout when the box arrives. i figure you will get your enbrel well before my orencia re-commences with infusions on April 14. keep us further updated and break out the party limo in May.
Ros
Good luck
Cindy
Ros
Mailed the Rx to the specialty pharmacy in Tennessee on Saturday March 1st.
and......
when's the injection party?
Ros
At the end you should see.....
........cricket.........
........cricket........
Just know that we think of you often
Peace
Bluedogs2
Was frustrated enough this morning to get on the phone again. I can hardly move this morning after a grocery run yesterday - plus this big storm over us. After my second cup of coffee I picked up the phone.....
First call was to Acreedo the specialty pharmacy. When I received the pre-authorization and my prescription, my insurance company told me to send the Rx to Acreedo. That was on March 1st.
Get the representative on the phone and explain that I am wondering what is happening with my prescription. After multiple times on hold while he looked into it, he tells me that my insurance does not cover mail order and my Rx has to be filled at a retail pharmacy. So why then did my insurance company tell me to send it to you? Then while on hold a 3rd time I was disconnected and had to call back and start all over with a different rep.
This one tells me there is no record of my Rx in their system at all. She has my information on her screen along with my pre-authorization, but no clue about and prescription.
So I then call my insurance company again and tell this rep my story. I ask her why I was told to send the Rx to Acreedo when Acreedo tells me they can't fill it. She puts me on hold to talk to her supervisor - then comes back to tell me that she is connecting me to Acreedo to see about getting my Rx filled - arrrggghh!!
Now I get an Acreedo rep who said she was a patient advocate. I like the sound of that as I really need someone to help me here. She has all my info, and says she does see where my Rx was received which was then sent off to their fulfillment center. Once at the fulfillment center it was not processed because of them seeing that my insurance doesn't cover mail orders. She talks about retail pharmacy some again - at this point I don't know if she means retail pharmacy like Rite-Aid or their own retail pharmacy. But she takes control of the situation and tells me that she is going to call my doc's office and request a new prescription be electronically sent to her. Then she will get it to the proper place to fulfill it for me. She says I should hear back from them within 48 hours with a phone call to make delivery arrangements. She also gives me a number to call if I don't hear anything after that 48 hours is up.
I'm exhausted after all that.
And the saga goes on..........