Tag Archives: prescription insurance

psoriasis, Psoriasis Treatments

Tremfya is much, much harder to get than I imagined

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I took this photo of the sunset over the ocean on last month’s Alaska cruise. It reminds me of calmer waters and more joyful times as I persisted in getting my Tremfya prescription right over the past few weeks since.

The journey began in May simply enough: get Tremfya renewed for another year at a new specialty pharmacy. I have continued to use my previous dermatologist’s prescription this year, but with a new doctor I needed a new prescription at a differeent pharmacy starting this summer.

My dermatologist and I decided to request every 6-week dosing, which we both thought would be denied. But it was worth a try, right? No. Denial came swiftly and ended up costing me a lot of time waiting and on the phone.

My dermatologist and I decided to request every 6-week dosing, which we both thought would be denied. But it was worth a try, right? No.

For me simple is never that simple when it comes to getting the newer, more expensive (good) medications to treat severe psoriasis.

(Barely) Qualifying to Receive Tremfya Coverage

After the DENIAL for every 6-week dosing schedule for Tremfya, I was glad to see they approved every 8-week schedule. It’s what I expected anyhow since it makes financial sense for the insurance provider to not pay more than it has to, even though I’ve shown I need a higher frequency dosing.

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With that letter describing how 6-week dosing is not covered, WHA did explain the criteria for receiving coverage for Tremfya. I couldn’t believe how incredibly restrictive the criteria are, including failing two of the newer medications/biologics:

WHA [Western Health Advantage] covers Tremfya when all the following criteria is met:

[1] when prescribed for moderate to severe plaque psoriasis confirmed by a dermatologist (psoriasis affects 10% or more of the body; psoriasis involves hands, feet, and neck or genitalia).

AND

[2] prescribed by a dermatologist

AND

[3] the patient has tried and failed topical therapy (e.g., Dovonex, Tazorac, or other topical steroids),

AND

[4] documented failure or clinically significant adverse effects to one of the following therapies alone or in combination, unless contraindicated: methotrexate or (if methotrexate in contraindicated) cyclosporine, acitretin, or a trial with PUVA or UVB for at least 3 months unless intolerant,

AND

[5] documented failure or significant adverse effects to at least two of the following: Humira, Otezla, Stelara, or Cosentyx.

Initial approvals are considered for 3 months to assess patient’s response and renewals for one year.

I couldn’t believe how incredibly restrictive the criteria are to receive Tremfya, including failing two of the newer medications/biologics.

This is how I imagine the insurance provider reviewer went about his job when fe came to my case: Continue reading →

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psoriasis, Psoriasis Treatments

8 Weeks with Tremfya: It’s Working!

The high temperatures are still in the 80s here in the Sacramento area, and I can wear shorts! My lower legs began clearing from psoriasis a few weeks after starting Tremfya.

On Monday I hit the eight-week mark on Tremfya (guselkumab), Janssen’s new biologic indicated for plaque psoriasis. Over the weekend, it felt like the remaining psoriasis started melting away as lesions flattened, looked less red, and even disappeared. Some psoriasis persists, primarily on those stubborn spots on my trunk/back. But, hey, I’m not complaining.

I’m excited about the response, but remain cautiously optimistic. I thought with this kind of response I might be jumping up and down. But Lori and I agreed that we’d like to see continued progress as we’ve had our hopes dashed so many times in the past.

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I’m excited about the response, but remain cautiously optimistic. I thought with this kind of response I might be jumping up and down.

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Maybe I’m in shock that I can’t bring myself to believe a medication might effectively treat my psoriasis apart from cyclosporine. The journey with Tremfya is only the most recent leg in a lifelong journey to find that magic bullet of a treatment to relieve me of psoriasis lesions.

Continue reading →

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psoriasis, Psoriasis Treatments

The Frustrating Road: Appealing the Insurance Denial

As I wrote in Insurance Request Denied for Otezla, I heard first from my dermatologist of the denial. The next day I received a letter detailing the denial. The crux of their argument for denial is that I’m already taking Enbrel (etanercept), a biologic, and no studies exist to show the efficacy of taking Enbrel and Otezla (apremilast).

I honestly didn’t expect too many studies of people taking Enbrel and Otezla. Otezla is only FDA approved recently. I understand many people with psoriasis would not need to take two high costing medications to treat their condition. Unfortunately, I am that person who needs a combination of therapies to even keep me at the high-level of moderate to low-level of severe. Forget about clearance or near-clearance.

Last week I finally conjured up the courage to call my insurance provider about the Otezla denial. Right away I knew why I procrastinated.

The call did not get off to a good start. She asked me my identifying information, which I gave all except my state. I figured this is a small HMO that is local, so California would be assumed. She told me twice that it was needed to identify me in their records. I felt annoyed already.

I learned quickly that my provider already filed an appeal on my behalf, so the call was essentially useless. I told her that I still wanted my perspective to be heard by the insurance medical reviewer. She told me that my perspective didn’t matter, only whether or not the medications prescribed are medically necessary.

More frustration. Some angry words exchanged. Then silent typing for five minutes.

I felt disoriented during the silence. Was she documenting my upset? Would I be denied insurance later if I pushed too hard for this medication? She assured me that wouldn’t be the case, that she only needed to document what happened on the call.

My condition, I reasoned, needs two medications to overlap. If the old one is stopped too quickly, the new one might not be strong enough to suppress the inevitable flare. I hope to only be on one medication eventually, but that takes time. More typing and silence.

I trust she took down what I wrote for the medical reviewer. But why couldn’t I share my experience and thoughts of my own medical care in the first place? I never did get a straight answer on that question.

Now it’s time to wait some more, up to 30 days. I’m starting to not even want to try this medication if it’s so much trouble!

 

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psoriasis, Psoriasis Treatments

Insurance Request Denied for Otezla

Today I found out that insurance denied my dermatologist’s prescription for Otezla (apremilast). With so many days passing before hearing I assumed the scrip ran into issues. So, I messaged my doctor to find out what happened over the past ten days.  The dermatology office will appeal the denial, which can take up to 30 days–though I’m told that most likely we will hear back earlier.

How do I feel about the insurance denial? I thought I might feel upset and angry, but I mostly shrugged it off. This insurance company, at least the prescription medication provider, is no doubt accomplishing their goal of wearing me down. They are already in my head. As soon as I received the prescription my first thought turned to whether insurance would approve it. I’m saddened that I would think that first.

Besides indifferent and somewhat sad, I feel mostly tired. For a long time, I’ve preached having a good working partnership with health care providers. I practice what I preach. I can talk to my dermatologist just about anytime about anything. We work closely together to decide on my treatment plan. That’s now not the problem.

How do I have a good relationship with the pharmacy benefits company my insurance contracts?

These issues really are new to me the past few years. From the time of my diagnosis until I took this new job in 2014. I was with Kaiser Permanente. I didn’t deal with insurance issues directly—it seemed if the doctor ordered something, I wouldn’t question if I would get it. Phototherapy, biologics, pills, and procedures were all covered.

I’m not looking forward to the next few days. It feels like each time I call I talk to a different person. All the same, I’m building up the courage to make phone calls to the insurance company this week. When they wanted to deny my Enbrel twice a week—claiming a once a week step down protocol that didn’t work for me—I pushed back hard. I overturned that denial with persistence, clear reasoning, and a calm approach.

Praying that I can keep that same calm, figure out what’s going on, and help the process along. I don’t have to have this exact medication. But I do need to feel some security and confidence that I can reasonably have access to what my doctor and I think are best for my psoriasis and health.

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