Grr... If I didn't hurt so much I'd throw something.
My insurance company denied my doc's orders for Orencia. Have been on Enbrel and Otezla with no improvement and a lab result makes her not want to order Humira/Remicade/Enbrel again.
Anyone else been denied coverage? I have good insurance (or so I thought). What steps did you take next?
Lorrie
You will have to appeal the decision... Doctor should know the steps...
Good luck to you hon..
Karen
I wouldn't hold my breath, as it is still very investigational. You got an automatic denial as would have from any insurance company Given your other failures you may get a special approval. It does have a completley different action than others.
Orencia typically more expensive for the insurance companies than other biologic and doesn’t really have better efficacy. Some insurance companies require you to be treated with at least two other biologics before approving. Have you tried Stelara? It’s a variant of the TNFi, but works in a slightly different way.
I tried Humira then Enbrel,followed by Remicade. I am now on Orencia,my insurance is BCBS,I have had no problem at all with switching. I believe my rheumie is smart by not directly labeling my disease thus enabling more choice.
Lindseylou raises a good point- is your diagnosis a bit vague?
I'm on Orencia. Did some looking into it. It's not approved for PsA. From what I could find, it was effective for joint problems in PsA peeps, but didn't do anything for skin symptoms. This may be why your insurance company bounced it back. I noticed in my online medical records just the other day that my current doc has me listed as something along the lines of "arthropathy with psoriasis" rather than PsA. Simpler than the "seronegative inflammatory polyarthropathy" I began with.
I had some not-cool reactions to both Humira & Enbrel: bleeding problems and a malar rash, raising concern about drug-induced lupus with both, plus a few confined to one drug or the other. I've had NO side effects from Orencia, and it does seem to be starting to make a good difference. I hope you can get this worked out.
Orencia isn’t the world’s best for skin, but a trial showed 53% obtained PASI 50 at 24 weeks.
So, Louise, does drug-induced Lupus go away when you quit the drug? All these things scare me about taking Enbrel. Is that a rare side-effect, cuz I never heard of it. Someone else had mentioned they got symptoms of MS from one of the biologics I think, too.
mataribot said:
Orencia isn't the world's best for skin, but a trial showed 53% obtained PASI 50 at 24 weeks.
Grandma J, don’t talk yourself into a reaction to Enbrel! Side effects happen, but they are rare.
Go ahead and encourage your doc to go through the appeals process. Sometimes it will be approved. If that doesn’t work, try for a different diagnosis, maybe that will get it going. Sometimes, just having the doctor certify medical necessity (again) in the appeal is all it takes though. Needed information: your demographics, insurance info, diagnosis, medical need, why/ how other treatments have failed.
Lololol Seenie!!! I have to chuckle--I should change my name to NegativeNancy!!! Don't worry, I won't! I've been afraid of meds and many other things since my childhood (Santa, flying, throwing up, etc) ..I like to call it cautious, hehe! I actually don't think my fears have ever created reactions or side effects, because I'm always pleasantly surprised when taking most meds I rarely have had a side effect. Someone had mentioned the doxycycline would have more side effects than Enbrel will-lucky me, i have 0 side effects from that!!!
Seenie said:
Grandma J, don't talk yourself into a reaction to Enbrel! Side effects happen, but they are rare.
Thanks, guys. I'm hopeful but waiting as the doc/IV Center/insurance all talk. All seem very nice but somewhere there's a disconnect.
good luck to others as well as they navigate similar situations!
Lorrie
So, Louise, does drug-induced Lupus go away when you quit the drug? All these things scare me about taking Enbrel. Is that a rare side-effect, cuz I never heard of it. Someone else had mentioned they got symptoms of MS from one of the biologics I think, too.
mataribot said:Orencia isn't the world's best for skin, but a trial showed 53% obtained PASI 50 at 24 weeks.
Drug anxiety is one of the top reasons people stop treatment for this disease. Your dermatologist will help you through the first shot. If you can’t bring yourself have someone else do it.
The drug induced lupus is reversible. TNFi may flare MS if you have the condition. There has been only been a handful of known cases of MS were the patient had no family history of it. I wouldn’t worry about it. Your doctor’s will monitor you via exams and bloodwork.
Grandma J, yes, it did go away. Most all of the side effects with the biologics do resolve without issue.
Lorrie, it sounds like you are trying for the infusions. Would they be more willing to play ball with injections?
Thanks! I bet it was scary--lupus is scary. Glad it went away. I just like to be in the know about everything. I feel that I am my best advocate and it would be ignorant not to have all the facts before going ahead with meds or tests or whatever. The one thing I didn't know until after I had several cat scans is that each cat scan is equal to hundreds of x-rays. That's great, because I would have declined having at least a couple of them had I known that sooner.
Louise said:
Grandma J, yes, it did go away. Most all of the side effects with the biologics do resolve without issue.
Lorrie, it sounds like you are trying for the infusions. Would they be more willing to play ball with injections?
My primary told me that most times the standard is 1. Deny automatically. Surprisingly a majority don’t appeal. 2. Appeal and get denied. Almost all give up at this point. Insurance wins. 3. Appeal again with added (non needed) paperwork from the doctor. 4. Repeat step 3.