Cimzia no longer covered by my insurance

If your doctor puts in for medical necessity, they will likely approve it. My insurance does not cover Simponi without a very large co-pay and says I should be taking Humira. However, my doctor put in for medical necessity since I had a bad reaction to Humira. It was approved and so I just pay the co-pay I would have if I was opn Humira.

This seems to be a common problem among insurers' formularies. But all companies have forms that your doctor can put in for medical necessity.

Actually, all insurers have formularies and levels [tiers] of coverage and associated levels of co-pays. This was pre-Affordable Care Act. Same with certain blood tests that they will pay towards. Example: Aetna considers the Serology 7 provided by Prometheus labs to be "experimental" while other insurers will cover it.

This is why it is so important for people to check their policies during open-enrollments to find out if coverage has changed.

Rango, I think if your were previously covered on medical necessity, then it is as simple as the doctor refiling the paper work again making the same request.

I should add that I do have Blue Cross Blue Shield of Louisiana with a plan that's specific to my company. <Not sure if that makes a difference or not.

@Jen77, I think that's the prescription length (or refills) not the insurance coverage.

@Ides, that's good to know. I just got off the phone with them and nearly was in tears. You know how it is when something is finally working and they want to take away your lifeline?

This may be an insurance tactic to move me to Humira. But I don't think that should be their decision. I'll contact my dr. first thing in the AM and see what he says. I've done so well so far, I don't want anything to change right now. I would hope Humira works just as well but I'm not ready to move onto another drug, when this one is working just fine, no side effects and great effectiveness.

I'll follow up and let yall know!

Thx!
Stephanie

FYI-- I spoke to the doctor's nurse who talked to the Cimzia local rep. They both said that the insurance company not covering Cimzia is incorrect. There is a new prior authorization process where the doctor has to complete paperwork, send in and get it approved by the insurance company. But since I've been taking Cimzia for a while, I should be able to continue with it covered by the insurance company.

I'll follow up here when it gets processed/approved. Yall might want to check your own meds for the new year, so there's no delay in getting them to you on time.

Thanks!!
Stephanie

Just an fyi... got my meds covered after the doctor wrote a letter to the insurance company. All good for one more year!!! Yay!

Thanks Ides. It kinda makes me angry that they would even try it after almost 4 years of successful treatment. I was going over my blood work today. My doctors have a new computer system that allows you to see all your test results since I started going there in 2010. And my C reactive protein and white blood cell levels are consistently lower every time I get it checked. And now they are finally within normal limits. It took almost 4 years to accomplish that on the same meds. Why risk changing the meds at this point to something that might not work? Wouldn't that cost them more in the long run with more ER visits, bloodwork, dr. visits etc. Just doesn't make sense to me. Oh well... I'll get off my soap box now.