Question about biologics

So I was wondering how many of you were approved for biologics by your insurance company, but did NOT have a positive RF or other positive test?

thanks guys,

nev 

My insurance company approved me for my Enbrel and I have never tested postive for any of the RF, Sed rates etc.

Have you tried the methotrexate and plaquenil already? if not that could be why? I'm not sure what starts with a Z? but then there are so many meds now...For me, I have been on the plaquenil for over a year and the methotrexate, tried all of the NSAIDs, and now going on three years later I am finally moving on to the Enbrel. I know that Methotrexate is also an injectable? but I'm not sure of the other name it goes by..sorry!

Insurance companies can be so frustrating and some of these meds are so expensive...my insurance company haggles over the cost of Lunesta for crying out loud! It can get pretty ridiculous I know!

Well Plaquenil is an option and many of us here have used it or are on it currently...do you just take one 2.5 a week? How many of the MTX pills do you take per week? I agree too much pred is never a good idea, and yet it works wonders!! That is how I ended up on the Enbrel because my doctor says that was an indication that I needed it since I did so well on the prednisone. I've been taking 8 pills at 2.5 mg of the MTX and it worked for awhile but then just stopped, and then I was able to move on to something else. I would take prednisone in a minute but my doctor is pretty stingy with it because of side effects. That is the only medication that gets rid of pain/inflammation completely and within a few hours for me..

My diagnosis is poly inflammatory unspecified whatever that means!! Do you take meds for fibro then? I'm surprised if you actually have something showing inflammation you can't get covered for the medication. Sorry to hear you are having such a difficult time

oh geesh nev!

you need help & bad!

oh boy lemme' see....usually w/ autoimmune diseases you'll go through "the ladder" of meds.  they exhaust all nsaids & cox2's & prednisone and then move on to plaquenil.

methotrexate is next & you can get that in an injectable definitely. it may work better than the oral form!

i'd ask the doc about that.

 

i did have the +RF in my labs and an sedrate.

you do see a rheumatologist right? and the diagnosis HAS to be "rheumatoid arthritis" or "psoriatic arthritis" in order to be approved.  some insurances will not approve a drug that is not within the scope of practice of say a General Doctor or PCP or family practice MD.

 

so perhaps the rheummy can RX injections of MTX.

can you get to a specialized Hospital for Bone & Joint Diseases?

 

then you'd move onto say the biologic Enbrel (some take MTX along with Enbrel too).  it's a weird High Tier drug that may need prior authorization in order to be approved by the insurance co.

Humira is TNF biologic injectable...it's $$$$$$$ too.

(both enbrel & humira have financial aid!!!!!!!! you enroll & Humira sends the meds to your door step at NO COST if you qualify, or it picks up a chunk of money where ins. does not pay).

Remicade you go to the hospital for an IV...i'm on that now, and it's covered by Medicaid and Medicare D.

Rituxan & Orencia are similar biologics given IV...

most meds do need a fight to get approved.

i'm sure many more folks will add their input.  pretty much everyone's been through this to some degree.

do you at least have pain meds in the meantime?

hang in there! this too shall pass.

erin 

Erin brings up a good point, there is "financial aid" and this was mentioned to me if I didn't have my health insurance there are other ways to help pay for the cost of Enbrel.

Erin? Are you sure you have to have a diagnosis of RA to get the Enbrel? None of my tests have ever returned positve, and on my sheet that I always take to the front desk it says "poly inflammatory unspecified" and I find it so frustrating to be going there for three years without ever having some kind of formal diagnosis. When I was on the phone with the mail order nurse, she asked me what my diagnoses was and I just said joint inflammation. The rheumy has never said I have RA.
Sorry to hear you have to sit in the chair! When I went in for my first practice injection...like an idiot I asked what the chairs were for..and the nurse told me they were for the Remicade patients and she said lets hope you can avoid "the chair".

Anyway back to the finances, I think there are ways to get around it because even with insurance, they were willing to pay my copay but somehow it turned out to be less and wasn't needed. I think you should look into it more. Enbrel works for so many people, its worth a try.

I'm happy to hear it work so well for you, I have almost finished my entire order of a 3 months supply and have not had that good of results.  My first injection was at the office by the nurse and now several weeks later and a few starts and stops, I feel better but it tends to run out about halfway through the week.  I feel pretty much the same minus some of my hip pain..if I get sick or something nothing helps not even the Enbrel.  Hopefully going to twice a week will help even more.

Congrats on your success! Let us know how it goes for you :)

Hi there,

I'm not really sure, I paid $40 for a three month supply of the 50mg injections (sub q's).  I doubt it since it is availabe in both 25 and 50..and for our insurance $40 is considered a top tier copay so we really can't go any higher for a copay. We have, 20, 30, and 40.

Thanks! I hope it works too, my body seems to be really stubborn when it comes to these kind of things and I really don't want to visit "the chair"