Insurance won't cover Rebif because I haven't tried Copaxone??
 

So I am still waiting on the Rebif I was supposed to start already, and the MS Lifeline people that the Dr sent the prescript to call today and tell me my insurance will deny it because I have never tried Copaxone or avonex. That is the stupidist thing I have every heard. That is like the insurance company denying your Darvocet because you haven't tried tylenol yet.


Has anyone else had this problem??

Sounds like the insurance company is manned by Rhesus Monkeys....wait, that's insulting to the Rhesus Monkeys.

It does sound weird and highly stupid. You should be able to take whatever MS injectible you want to take, I dont think you need to try them in any specific order...

I didnt choose Copaxone because it was the first letter in the CRABs acronym, I tried it first because I didnt want the "interferon flu" every week. (so far it seems to be working...or at least not causing me huge problems)

Hopefully they'll let you try whatever med you want, without requiring you to take a different one first.

That's a new one to me.

I've heard of Copax being the only one some companies approve for CIS or "probable" MS. (mine was one of these)

I've heard of needing to take one or two of the CRABs before trying Tysabri.

But never heard of a preference among the CRABs before. :confused::confused::mad:

That is not unexpected, it seems that Teva discounts the Copaxone to insurance companies to get them to give it preferential treatment. Usually if your Doctor writes to them and appeals the decision they will allow the Rebif.

Now I'm confused!

My coworker and I were discussing our costs of meds. We're on the exact same insurance plan/coverage. She is on Betaseron (or is it Betaferon?) and I'm on Copaxone. My Copaxone is actually less than her Betaseron.

This is the first I'm hearing of Copaxone being the 'must have tried' medication before another is considered.

that sounds ridiculous to me too.
they can't prescribe. only the dr can do that.

i'd get your dr's office involved in this. maybe they can intercede and clear the problem up.
otherwise i'd appeal it.

I know someone who couldn't get Avonex paid for but her insurance company did Beta. I have given up trying to figure out any rationale for their behavior. It does seem that their first action is always to refuse things but if you pursue it often they will approve.

I guess the other option if you are really set on this med would be to contact the company and see if they will cut you a deal if you pay out of pocket. Good luck.

I think Bill is right, and it probably has more to do with them cutting a deal with Teva and Biogen. My friend in the US VA had to go on Betaseron first, apparently for the same reason.

They give you a choice of one type of interferon (out of the three options), or Copaxone, . . . so I suppose they reckon you aren't really being "limited". Betaseron is a different type of interferon, but Avonex and Rebif are exactly the same drug anyway; it's just the dosage that is different.

Cherie

My old insurance was the same way. Didn't matter much to me as my drug of choice was Copaxone anyway.

I called them and asked about using another drug because at one point I was still considering Rebif. I was told that if the Copaxone didn't work or the doc wrote something giving a reason why another drug was preferable, there wouldn't be a problem.

isnt is sad that we live in a world where we MUST neogiate with our insurance companies? no longer can our MD write our lil white unreadable script of paper, and tell us to go see John at the pharmacy who will take good care of us. Now you have to fax in triple the original script while applying for an exception, and a request for an "off formulary" medication. You must provide proof that you suffer from the disease, and will use the medicine in a "ON LABEL" usage as approved by the FDA. If your med is for OFF label use, you must call another agency. Sad...just sad.


My question is...

If Rebif is the SAME drug as Avonex, only stronger, and more frequently, WHY is Avonex not cheaper? Its LESS of the same med, and only ONE shot per week, versus rebif being MORE med, and MORE supplies as in three times a week, yet, the cost remains virtually identical.

Who makes up these rules? :confused:

I was told by my mail order pharmacy that the prices change according to how the stock market for the drug is doing at the time. Yes, I find it all very sad too.

Going on memory, which isn't THAT great ;), Avonex was the first of that type of interferon that was researched and put on the market. (Betaseron was already on the market, but a different type of interferon.) Biogen came along with Rebif, and virtually all they had to do was double the dosage, run a 6 month trial to prove increased efficacy, and that was enough to get it on the market. (They eventually carried on with the two year, then a 4 yr trail though ...).

The makers of Avonex put up a pretty good fight that they had a patent on that interferon, but Biogen won the fight based on interim efficacy numbers. In the end, I think Rebif didn't prove to much more effective, but the patent was broken by that point anyway . . .

It seems that neurologists (and insurance companies) make their "recommendations" based on affiliations more than anything else. All of the CRABs have basically the same efficacy, so it doesn't really matter what they recommend or cost. Ultimately the decision is often based on tolerance though.

Cherie

I think a phone call from your doctor will clear this up. All the drugs are discounted.

Beta 1b - betaseron, was approved first. In August 1993 (I drew number ~ 27,000 in the lottery for it). Beta 1a - Rebif and Avonex, came later. COP II - copaxone, I think came last in the approval process. And yeap, there was a COP I. There's also some 30 other drugs that were in trials at the same time that didn't make the FDA cut.

They all have roughly the same efficacy, so I can't see why an insurance company would lean one way or the other unless they're getting a skewed discount on any particular day.

Tom

Thanks you guys! I thought it was just me! I called the doc they are putting in a request for an appeal and hopefully by the new year I can have my meds. The doc wants the Rebif as opposed to the copax because he has seen better results with his own patients. But again my choices are limited to 3 I don't think the insurance company who I pay for every month should have a right to tell me no.

Really? Wow.

I don't understand any of the red tape and how this all works... but I get my medication through a pharmacy (walk in) and I'm covered by my work insurance + a copay from the Copaxone assistance program.

I never saw a change in the cost of my medication versus the stock market. Is it a quarterly or annual change? That's rather interesting...

I just went and looked on the NYSE. It can change daily,hourly, etc.. Look at this
http://www.nyse.com/about/listed/lcd...ml?ticker=TEVA