Anyone have luck fighting insurance company on requiring you to "try" a drug?
 

I'm on Avonex and doing amazingly well. Before I accepted a new job in Nov. I checked, same insurance plan, same doctors, same drugs ...golden. I had turned down a better job earlier in year just because Avonex wasn't on their formulary. New year & they switch insurance...Avonex is on their formulary but not preferred so they are denying saying I have to go on Copaxone. What do you do? It is totally illogical for them to mess with a therapy that works when it is on their own formulary. One hospital stay from an adverse reaction to a new medication will negate any kickback they get from the drug company. I travel alone for work and the idea of having some of the reactions I've heard about scares me. I've had hotel room doors broken down and ambulance trips alone to hospitals in other states before MS diagnosis. I have no desire to do this again because of a drug reaction from Copaxone. I have no more Avonex and no "emergency" doses left from the manufacturer...I don't want to relapse. I just want to cry. Any ideas?

i feel for you. it's maddening how you can pick a plan and be locked in and then they can change whatever they want.

i would enlist your dr's help to override this decision. there is a process the dr can do. i don't remember what it's called. i did this one yr for a sleep drug and they covered it for a yr.

MS tx is too important for them to get away with this.

Nancy- I think it is called an appeal.

Mcsisters- It doesn't make sense since one is an interferon (Avonex) and one is a myelin mimic (Copaxone).???

BTW, I fought long and hard to stay off of Copaxone because I was scared of those IPIR reactions. After I realized that my depression was from being on interferons, I switched to Copaxone reluctantly and have been on it for 8 years w/o a reaction.

I realize everyone is different but it turned out to be very good to have the depression lifted. Of course, I had thought it was "just MS."

Best to you,
ANN

There is a basic appeals process, but your doctor must support your need for the drug you prefer. I went through this with a drug I am on, and the doctor showed that it was the preferred treatment due to efficacy, fewer side effects, and because I was doing well on it. You can even protest that you have always reviewed this drug on an different "tier" and protest higher co-pays, if that is involved.

Get with your doctor and go through the appeal. Most of the time if you are already on a drug, they will not make you change. It is generally new patients that they try to steer to the cheaper options as their first choice. Because you are new to this insurance plan, they see you as a new patient and are treating you accordingly. Once your doctor shows them your history of already taking avonex, you should get approved for it.

My experience has been with another ailment, Polycythemia Vera. I tried all the chemos for that and could not take any of them--had ER visits, horrid side-effects, well documented by hematologist. So when I went for p32 radiation (which worked without side effects) I never had to apply. Mayo Clinic took care of all that. Taking p32 is now so rare, since the chemos are available, that the gov't probably just said forget worrying about it. But actually I don't know if that attitude will persist if I am asked to go for a third time for p32 at Mayo....I hope I don't have to go, even though being at Mayo was quite an experience in many ways, and their neurologist was great (had not seen a neurologist in years, found them hopeless for me).
As far as other drugs go. I now have to pay twice as much for Synthroid as before. But so far I have just paid rather than try to prod the hornet's nest. All doctors say that I need to take the Brand Name, Synthroid, even if I am OK with other generics. My pharma has been great about special ordering certain generics for me, such as one particular company's "Propanalol", since I have some reaction to other companies' Propanalol. So far I have not had to "fight" for the big ones.

I never tried an MS drug. I read the box label for Betaseron (is that the name, it's been a while?) and decided that I was already depressed and didn't need to chance it. My neurologist didn't think it would do any good anyway, and thought my MS was sufficiently under control to not risk trying anything new, with my drug sensitivity. I realize now that Betaseron would have had me in the hospital with a purple toe, bradycardia, and difficulty breathing, because I did try the Alpha Interferon drugs for Polycythemia Vera, and the result was "purple toe", extreme neuropathy, bradycardia, etc. My sensitivity has kept me sometimes for having to "fight" to get drugs--I just would have to fight the drug itself.

i had a hx of depression and went on copaxone in '03. i stayed on it for 10 yrs without problems. i was so stable that i decided to stop it and thank God i've con't to be ok. my neuro concurred.

i would stay with what works for you.

It would be very unusual for them to turn you down if your physician provides them with a prior authorization request. Definitely contact the office and tell them what is going on.

Good luck I would not be in favor of having to try another medication either. Please let us know how it works out.

don't forget to mention in appeal that you have 1) a history of adverse drug reaction on Copaxone and 2) thus request for coverage of your Avonex at lower tier price:wink:

Thanks everyone
 

My Neuro did the pre-cert, appealed and even got on the phone with the insurance's doctor who he said was a egotistical jerk. I got a second letter from the insurance after this and they offered Rebif. Since this is same drug essentially as Avonex, I am going to try it. No depression, but I do cry at sappy commercials now :)